Ballyhenry Form AM2

Ballyhenry Form AM2

Parental Request for School to Administer Medication
Staff at Ballyhenry Primary School will not administer any medication to any pupil
without the completion of this form. On completion, the Principal will liaise with the member(s) of staff concerned and request their willingness to administer.
Pupils Details
Pupils Name

First NameLast Name
Date Of Birth

DayMonthYear
Date
Condition
Class
Today's Date

DayMonthYear
Date
Medication
Name / Type Of Medication (as described on the container)
How long will your child take this medication for? Also please provide date dispensed
Full directions for use:
Dosage and method:
Time/s required to be taken
Any special precautions to adhere to:
Any side effects:
Can it be self - administered?
Contact Information
Name

First NameLast Name
Phone Number

WorkMobile
Specific Contact Number?
Relationship To Pupil
I understand that I must deliver the medicine personally to the Principal or agreed staff member and accept that this is a service which the school is not obliged to undertake.
Parent Name
Parent Name
Today's Date

DayMonthYear
Date
Signature Of Parent(s)

Clear
Please confirm you have read the Administration of Medications Policy.

Yes
Should be Empty: