The school will not give your child medicine unless you complete and sign this form.

Details of Pupil

Surname
Forename(s):
Address
Date of Birth
Boy or Girl
Boy
Girl
Class
Condition or illness:
Other medications taken by the child:
Allergies:

Medication: Parents must ensure that in date properly labelled medication is supplied.

Name/Type of Medication (as described on the container):
Add a photo of the prescription box label (showing dosage and patient name) *
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Date dispensed:
Expiry date:
Full Directions for use (Dosage and method)

NB Dosage can only be changed on a Doctor’s instructions

Timing:
Special precautions
Are there any side effects that the School needs to know about
I understand that I must deliver the medicine personally to (agreed staff member name):
I accept that this is a service, which the school is not obliged to undertake. I understand that I must notify the school of any changes in writing.
Yes
No
Parent Name
Date
Please upload a copy of your signature*
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Submit

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Upcoming Events

29 Sep
After School Gymnastics club
Date Wed, 29-Sep-2021 3:30 pm - 4:30 pm
30 Sep
After School Club
Thu, 30-Sep-2021 3:30 am - 4:30 am
1 Oct
PFA Cake Raffle
Fri, 01-Oct-2021 8:30 am - 9:00 am
1 Oct
Swimming lessons
Fri, 01-Oct-2021 1:00 pm - 3:00 pm

Contact the School

Wilbarston Church of England Primary School
School Lane,
Wilbarston, Market Harborough
Leicestershire LE16 8QN

Telephone: 01536 771252
Contact the School Office by Email

Send us a Message


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