Prescribed Medicines Permission Form

Class/Tutor Group: *

Child's name: *

First Name Last Name

Date of Birth *

Day Month Year

If your child requires regular medication, the school requires you to provide authorisation to dispense the medicines.

Medications MUST be handed to the nurse by a responsible adult (parent or helper). No medications will be accepted from students.

Remaining medication will not be sent home with a child – a parent or carer will need to collect it from our medical room.

Medical Problem *

Medication Details *

Time of last dose *

Duration of Prescription *

Last date medicine to be administered *

Prescribing Doctor Name *

Prescribing Doctor Surgery *

Prescribing Doctor Phone number *

I authorize Discovery Bay International School to administer the following medicines to my child:

I authorize Discovery Bay International School to administer the above listed medicines to my child:*

I have read and understood the attached Prescribed Medicines Statement and accept them fully.

I have read and understood the attached Prescribed Medicines Statement and accept them fully. *

The name of medicine, date (prescribed by a doctor within 7 days), student’s name, dosage and route of administration is marked clearly on each medication bag/bottle.

The name of medicine, date (prescribed by a doctor within 7 days), student’s name, dosage and route of administration is marked clearly on each medication bag/bottle. *

Parent/Guardian *

Prefix First Name Last Name

Parent Email *

Parent Mobile *

Signature *

Authorisation Date: *

Day Month Year