SET PERMISSION TO ADMINISTER PRESCRIBED MEDICATION FORM

It is our policy that our staff will administer prescribed medication to your child if this form is properly filled in and signed by a
parent/guardian. Please note that we will only accept medication that has been prescribed for the child in question and which
is in its original container with its label and instructions intact and legible. Please note that if more than one medication is to
be given a separate form should be completed for each one.

Name of school:
Name of child

Date of birth

Form/Class/Group

Medical condition (optional)

Name of medication (on label)

Strength of medication (on label)

Date dispensed

Dosage and method (on label) Expiry date (on label)

Timing (when to give) How often taken (on label)

Length of time to be taken

Any other info

Contact details of parent(s)/guardian(s)

Name(s)

Relationship to child

Home telephone(s)

Work telephone(s)

Mobile telephone(s)

The above information is, to the best of my knowledge, accurate at the time of writing and I hereby give permission for the
staff to administer the above medication to my child in accordance with the SET policy on the administration of medicines. I
understand that I can only leave medication that has been prescribed for the child in question and which is in its original
container with its label and instructions intact and legible. I understand that if there are any changes to the medication it is
my responsibility to inform a member of staff.

Signed

Full Name (print) Date

Staff Signature

Full Name (print) Date