Medication Form for new pupils

Pupil's Name:* Pupil's Class:* Pupil's Date of Birth:*

The above pupil requires the medication:*ProphylacticallyWhen an incident occursRegularlyAs and when required

Details of medication:*

Where the above named medication is a “salbutamol inhaler”, I give my permission for my child to use the school’s emergency inhaler should my child’s be broken, mislaid or not readily obtainable.

Reason for medication and what date to continue until:* Exact instructions on administering medication:* Cleaning Maintenance Requirements. Please note that this cannot be undertaken at school, but we need to know how frequently you will be taking equipment or medication home for cleaning / renewal / replacement*

*I confirm that the medication has been prescribed by a medical doctor, and give permission for members of Greenfield staff to administer it, according to the instructions above.

*I understand that staff cannot be held responsible for loss or damage to the equipment, nor for any medical condition which arises subsequent to administering the medication.

*I undertake to inform Greenfield School of any changes which may occur in my child’s requirements with regard to the medication.

Signed:*