Parkside Primary School

Record of long term (over 7 days) prescribed medicine administered to an individual child

Please complete fully before bringing medicine into school.

Name of child

Date medicine provided by parent/guardian

Group/class/form

Quantity and date received

Name and strength of medicine

Expiry date

Dose and frequency of medicine (please state times)

Quantity and date received (do not complete, for school use only)

Your child will be given/supervised whilst he/she takes their medication by (do not complete, school will input name of staff)

This arrangement will continue until the end date of course of medicine/until instructed by parents/guardians.

I agree

Name of adult completing form

Please tick to act as your electronic signature

I confirm this acts as my signature

Date of signature

Relationship to child

Staff signature (school to complete)

Date staff signed (school to complete)

Staff role (school to complete)

Our use of cookies

We use necessary cookies to make our site work. We'd also like to set optional analytics cookies to help us improve it. We won't set optional cookies unless you enable them. Using this tool will set a cookie on your device to remember your preferences.

For more detailed information about the cookies we use, see our Cookies page

Necessary cookies

Necessary cookies enable core functionality such as security, network management, and accessibility. You may disable these by changing your browser settings, but this may affect how the website functions.

Welcome to Our Website!

Record of long term (over 7 days) prescribed medicine administered to an individual child

Contact Us

Our use of cookies

Necessary cookies

Parkside Primary School

Welcome to Our Website!

Record of long term (over 7 days) prescribed medicine administered to an individual child

Contact Us

Our use of cookies

Necessary cookies

Analytics cookies