Medication Form

Hackleton CEVA Primary School

Medication Form

Please complete this form to authorise the school to administer medication to your child.

Name of child: *
Date of birth: *
Class: *
Medical condition/illness: *
Name of medication (as described on the container): *
Dosage, method and timing: *
Start date *
End date
Other information:
Does the medication need to be kept in the fridge?
Yes
No
Parent signature: *Please use your finger or mouse to sign
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