Please note this is only a test
| Instructions: Please copy text below and paste into a blank email. Fill in the boxes then send your email to david.horne@chalkwellhallinfants.co.uk |
Parental agreement for Chalkwell Hall Infant School to administer medication
Chalkwell Hall Infant School will not give your child medication unless you complete and sign this form. This school has a policy that the staff can volunteer to administer medicine. (Medical Conditions Policy)
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Name of School |
Chalkwell Hall Infant School |
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Name of child |
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Date of birth |
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Class |
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Medical condition or illness |
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Name of person bringing medicine in to school |
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Date medication was brought into school |
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Medicine Name/type/form of medicine (as described on the container) |
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Medication amount supplied |
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Date dispensed (prescription only medication) |
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Expiry date |
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Agreed review date to be initiated by |
Emma Howe |
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Dosage and method regime |
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Has a dose already been given today? If so, what time was this? (Please be aware you will need to notify the school of each dose given at home prior to the start of the school day. Without this information, the school will be unable to administer your child’s medication). |
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Times medication to be administered |
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Dates medicine is to be taken |
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Does medication need to be taken at After School Club? If so, please state the dosage amount and time medication is to be administered. |
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Are there any side effects that the school needs to know about? |
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Is your child on any other medication? If so, please state what medication |
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Self-administration |
Yes/No |
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Procedures to take in an emergency |
Contact Details
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Name |
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Daytime telephone no |
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Relationship to child |
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Address |
I understand that I must personally deliver the medicine to the Infant School Office.
I understand that this is a service that the school is not obliged to undertake.
I understand that I must notify the school of any changes in writing.
I understand that I must collect all medicine when it expires and/or at the end of the school day/year.
Signed: _____________________________________ Date:___________________________