Titchmarsh Church of England Primary School

Northamptonshire County

Council Education department

ADMINISTRATION OF PRESCRIBED MEDICATION

Due to my inability to visit the school to administer prescribed medication

to my child(Name)_________________________ Year____________

I request that the medication is administered on my behalf and I give my

permission for a qualified First Aider to administer:-

Medication________________________Dosage_________________

at__________________

Signed____________________________Print Name_____________

Date of Request____________________Prescribing doctor_________

School only/send home at 3.30 (please circle).

Please fill in the form and hand into School office on first day of administration.

Note Only prescribed medication can be administered by school

J.Milton