BPP Medication Administered

Medication Administered - Parent Form

This form is to be completed by a Parent/Guardian in order for the staff to administer medication to students. This form will need to be completed every 12 months or when the medication changes. Please fill out seperate forms for each medication required.
Student Name*

First NameLast Name
Student Date of Birth

DayMonthYear
Date
Name of prescribing Doctor/Surgery
Phone number of prescribing Doctor/Surgery
Include area code for landline eg. 02 666 6666
Name of Medication*
Dosage time/s for relative medication to be administered
eg. 11:00am
Guidelines for administering medication, including dosage
eg. with food and water, including dosage amount
YesNo
Maximum Dosage in 24 Hours*
eg. 2 tablets
Minimum Dosage in 24 Hours
eg. 1 tablet

YesNo
Please describe all side effects for the required medication, and action plan in case of side effects
When will the school cease administering this medication?
eg. when the prescribed dose runs out, when medication ceases
YesNo
If answered yes please state the name of medication, a seperate form must be filled and signed if needing to be administered by the school at functions that exist outside school hours
YesNo
Yes
Yes

Parent Name*

First NameLast Name
Parent email - provide your email if you wish to receive a copy of this form
I, Parent/Guardian authorise school staff to administer the above medication to my child, named above. I understand that;

It is my responsibility to provide the medication in the original container, properly labelled with the child's name, medication name, dosage, and any other relevant information. I will inform the school in writing of any changes to the medication or dosage. I will provide updated medication as needed and collect any unused medication at the end of the treatment or school year. I also give permission for a school representative to contact the prescribing doctor if confirmation or information about this is required.
Signature*

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Medication Administered - Parent Form