Consent Form to Administer a Mild Pain Reliever

 Childminder must be informed daily on child’s arrival of time and dosage of mild
pain reliever last administered.
 Parent must be informed daily on the child’s departure the time and dosage of
mild pain reliever last administered.
 Each mild pain reliever product will be stored appropriately.

I ( parent / guardian name)____________________________________________

hereby agree to give my permission to

(childminders’ name ) ____________________________________________

to administer a mild pain reliever _______________________________ (name of medicine)

to my child _____________________________________________ (name)

at his/ her discretion in the case of emergency e.g high temperature or teething.

Parent / guardian signature: ________________________Date: ______________

Childminder signature: ____________________________ Date : _____________

Jolly Rascals, 7 Heol Gwyndaf, Llanishen ,Cardiff,CF145QB, Tel:07506390600