Medicine Permission Form
MEDICINE PERMISSION FORM
CHILD’S NAME: …………………………………………
CLASS: ………………….
I authorise the following to be administered to the above named child by staff of St Peter in Eastgate Infant School,
Date medicine to start ………………………………………………………………..
Finish date …………………………………………………………………………….
Medicine to be taken: ………………………………………………………………..
Dosage: ……………………………………………………………………………….
When to administer the medicine: ………………………………………………….
Reason for this medication to be given: ……………………………………………
………………………………………………………………………………………….
Doctor’s name: ……………………………………………………………………….
Doctor’s telephone number: …………………………………………………………
I understand that whilst all best efforts will be made, staff of St Peter in Eastgate Infant School accept no responsibility whatsoever for omitting to administer this medicine or administering the medicine at a time different from that specified above.
Signed: …………………………………………………. (Parent/Guardian)
Date: …………………………………