Havelock Schools - Administration of Medication Form

Infants : 01536 760486
Juniors : 01536 760361

Havelock Street, Desborough
Northamptonshire, NN14 2LU

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Details of Pupil

Surname

Forename(s):

Address

Date of Birth

Boy or Girl

Boy

Girl

Class

Condition or illness:

Other medications taken by the child:

Allergies:

Name/Type of Medication (as described on the container):

Add a photo of the prescription box label (showing dosage and patient name) *

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Date dispensed:

Expiry date:

Full Directions for use (Dosage and method)

Timing:

Special precautions

Are there any side effects that the School needs to know about

I understand that I must deliver the medicine personally to (agreed staff member name):

I accept that this is a service, which the school is not obliged to undertake. I understand that I must notify the school of any changes in writing.

Yes

No

Parent Name

Date

Please upload a copy of your signature *

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Submit

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