St Saviour’s Primary School, Toowoomba eNewsletter

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Administration of Medication at School Record

Parent/Guardians are to complete this form for any medication that is to be administered by school staff during school hours. Any medication administered by school needs to be labelled by a chemist with the recommended dosage.

Student First Name *

Student Last Name

Student Date of Birth *

Parent/Carer First Name *

Parent/carer Last Name *

Contact Phone *

I request that school staff administer the following emergency/routine medication to my child, if required, during school or school-related activities, as specified in this section.

Name of medication and treatment (eg Amoxicillin - Viral infection) *

Dosage (eg. 1 tablet) *

Mode (eg. by mouth) *

Indications for use (eg. one tablet three times daily with food) *

Expiry Date (as listed on container) *

Please indicate how long medication is to be administered for (eg. number of days or end on specific date) *

Name of Doctor

Contact phone number of Doctor

Name of Pharmacist *

Medicare Number *

Parent/carer Signature *

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Clear

Write your signature above the line