Medication Form - Greenfield School

Pupil Name:

First

Last

Pupil Class:

Pupil Date of Birth:

The above pupil requires the medication:

When an incident occurs
Regularly
As and when required
Prophylactically (as a preventative measure)

Details of medication:

Is the above named medication a salbutamol inhaler?

Yes
No

I give my permission for my child to use the school's emergency inhaler should my child's be broken, mislaid or not readily obtainable.

Yes
No

Reason for medication and expiry dates if applicable:

Exact instructions on administering medication, including time and frequency:

Does your child experience any side effects from this medication?

Yes
No

Please give more detail regarding side effects:

Cleaning/maintenance requirements. Please note that this cannot be undertaken at school, but we need to know how frequently you will be taking equipment or medication home for cleaning / renewal / replacement:

I confirm that I will send this medication into school in a clear, named, plastic bag or box.

Yes

I confirm that the medication has been prescribed by a medical doctor, and give permission for members of Greenfield staff to administer it, according to the instructions above. I understand that staff cannot be held responsible for loss or damage to the equipment, nor for any medical condition which arises subsequent to administering the medication. I undertake to inform Greenfield School of any changes which may occur in my child’s requirements with regard to the medication.

Yes

Signed: