Administration of Long-Term Medication

Please complete this form if your child has been prescribed medication requiring administration at school.

"*" indicates required fields

Step 1 of 4

25%

Pupil Name*

First Last

Select a school*

Junior School

Senior School

Date of Birth

DD slash MM slash YYYY

Form*

Diagnosis

Prescribed Medication, dosage and time medication is to be given, as prescribed by GP/Hospital

Medication Name

Dosage

Time to be given

Start date

DD slash MM slash YYYY

End date

DD slash MM slash YYYY

Medication Name

Dosage

Medication Name

Time to be given

Start date

DD slash MM slash YYYY

End date

DD slash MM slash YYYY

Dosage

Time to be given

End date

DD slash MM slash YYYY

Start date

DD slash MM slash YYYY

Please check the relevant boxes below*

I hereby give my permission for a First Aid trained staff member to administer medication to my daughter.

ONLY the School Nurse may administer medication to my daughter.

Please inform the School Nurse immediately if any changes are made regarding the above details. (nurses@talbotheath.org)

Please type in capitals the name of the person completing this form to confirm your form submission: **

First Last

Date

DD slash MM slash YYYY

Data Protection: Talbot Heath School Trust Ltd, as a Registered Data user, has an obligation to comply with the principles of the Data Protection Act 1998. Any personal details collected on this form will only be used for the purpose(s) stated. This information will be kept securely and will not be passed on to any third parties without the data subject’s consent. Information will not be kept longer than is necessary. Any queries regarding Data Protection should be sent to the Headmistress.