Medicine Administration Form

Parental agreement for school / setting to administer medicine.

Woolgrove School will not give your child medicine unless you complete and sign this form and the school.

If your child requires more than one medication, you will need to complete one Form 3B per medication needed.

Company

This field is for validation purposes and should be left unchanged.

Child's name(Required)

Class / year group(Required)

Name of medicine(Required)

Strength of medicine(Required)

What is the medication for(Required)

Expiry date(Required)

How much to be given (dosage)(Required)

When to be given(Required)

For example: lunchtime, 12:30pm, as required

Any other instructions

Number of tablets / amount of liquid medicine given to school(Required)

PLEASE NOTE: medicines must be given to the school in their original container / packaging, with a named label as dispensed by the pharmacy.

Contact name(Required)

Telephone number(Required)

Email(Required)

Doctor's name(Required)

Doctor's telephone number(Required)

Agreed review date to be initiated by

Review date

Signature

Print name(Required)

Woolgrove School Special Needs Academy,
Pryor Way,
Letchworth Garden City,
SG6 2PT

Tel: 01462 622422
Fax: 01462 622022
admin@woolgrove.herts.sch.uk

Mon-Thurs: 9.00am-3.00pm
Fri: 9.00am-2.00pm
(29 Hours per week)