A Primary Trust
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Riverbridge Primary School

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.

Please tick the box if you agree to:*
Please tick the box if you agree to:

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 medicineDosageTime of day requiredCompletion date of courseExpiry date of medication
Medicine 1
Medicine 2
Medicine 3
Medicine 4


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

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Riverbridge Primary School