Riverbridge Pupil Medication Request

Where possible the need for medicines to be administered at school should be avoided. Parents are therefore requested to try to arrange the timing of doses to avoid lesson time and the subsequent impact on your child's learning.
We will administer medicines to your child as close as possible to the requested time.

Once submitted, a copy of this form will be sent to your supplied email address for your records.

Child's name* Child's class* Contact number should we need to contact you about this medication* Contact email*

Please tick the box if you agree to:*members of staff administering medicines/providing treatment to your child as directed below or in the case of an emergency, as staff consider necessary.

Please tick the box if you agree to:my child will be responsible for the self administration of medication as directed below

Reason for medication e.g. sore throat, asthma etc.*

SCHEDULE OF MEDICATION:
Please record below the medication you wish your child to receive while at school.
Please note that if no completion date is recorded medicine will only be given to your child on the first day the form is submitted to the school office.

I wish for my child to receive the following medication:

	Name of medicine	Dosage	Time of day required	Completion date of course	Expiry date of medication
Medicine 1
Medicine 2
Medicine 3
Medicine 4

Special instructions: Allergies: Any other prescribed medicines your child takes at home: In lieu of signing a paper copy of this form I hereby confirm all information provided on this form is accurate (please type your full name as parent or carer):* Date of request (DD/MM/YY)* Contact email:

OFFICE USE ONLY

Parents/Carers of Early Years children
By signing below I acknowledge that the requested medication was administered to my child:

Parent Signature: Parent Name: Date: Please enter Please enter Please enter

Riverbridge Pupil Medication Request

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