Parental Agreement for Luckley House School to Administer Medicine

    Pupil's name

    Pupil's Form Group

    Reason for the medicine

    Prescribed or non-prescribed medication

    Name and strength of medicine

    Expiry Date

    Dose and frequency of medicine

    Date and Time given (time of day)

    Length of Treatment

    Date medication provided by parent

    Quantity Received


    Name of person submitting this form


    The school nurse/first aider will not administer prescription medicine without a completed form. A separate form is required for each type of medicine.