Preparing Children for a Successful Future
Planned review date:
Person to initiate review:
Contact Details:
Name:
Daytime telephone no.
Relationship to child:
Address:
I will deliver the medicines personally to the School Office
The above information is, to the best of my knowledge, accurate at the time of writing and I give
consent to school/setting staff administering medicine in accordance with the school/setting
policy
Parent/Guardians signature___________________
Print name __________________ Date ____________
Surplus/unused medicines:
The following quantity __________of the above medicine was collected by:
Name:_____________________________________________________________
Signed:____________________________________________________________
Date:______________________________________________________________
The above medicine was not collected. It was taken to _________________________
Chemist for safe disposal. Date: _________________ Initial: ________________
