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.