Medical Form

Parental Agreement for Ilchester Community Primary School to Administer Medicine Ilchester School will not give your child medicine unless you complete & sign this form.

THIS FORM WILL BE RETAINED FOR ONE FURTHER YEAR FROM THE DATE OF WHICH THE PUPIL LEAVES THE SCHOOL AND THEN SECURELY DESTROYED IN LINE WITH THE SCHOOL’S RECORD RETENTION SCHEDULE AND AS SET OUT IN THE SCHOOL’S MANAGING CHILDREN WITH MEDICAL NEEDS POLICY.

Name of child* Date of Birth* Class Number* Medical condition or illness* Name/type of medicine (as described on the label)* Date dispensed* Expiry date* Timing* Special precautions/ other instructions* Any known side effects?* Self-administration* Procedure to be taken in emergency*

NB: Medicines must be in the original container as dispensed by the pharmacy

Contact Deatils:

Name* Daytime telephone number* Relationship to child* Address*

I must deliver the medicine personally to the School Office*I understand

The above information is, to the best of my knowledge, accurate at the time of writing and I give consent to Ilchester School staff administering medicine in accordance with their school policy. I will inform Ilchester School immediately, in writing, if there is any change in dosage or frequency of the medication or it the medicine is stopped.

Name* Date*