FORM 4: Annual Administration of Medication Form

TO: The Chairperson of the Board of Management, Hansfield Educate Together National School

I / WE:

* Indicates required field

Parent/Guardian 1 name *

First

Last

AND

Parent/Guardian 2 name *

First

Last

THE PARENT(S)/GUARDIAN(S) OF:

Child's Name *

First

Last

GP Name *

GP Practice Name/Address *

Line 1

Line 2

City

State

Zip Code

Country

GP Phone number *

Please state medical condition: *

Class *

Please provide initial instructions - frequency/dose of medication and any comments in advance of Care Plan being put in place: *

a pupil in Hansfield Educate Together National School hereby request the Board of Management to authorise the School Principal/Class Teachers/ Additional Needs Assistants to administer medication to our child should the need arise.

We also request that any special arrangements be facilitated where possible.

We are fully aware that neither the school authorities nor those administering the medicine will be held responsible for any adverse consequences that may arise following the administration of medication.

We will also ensure that the medication is presented to the School Principal in a suitable container together with a photograph of our child, emergency contact numbers and clear instructions on when and how the medication should be administered. We will further ensure that these details are always current.

By submitting this form I confirm have read and am in agreement with the terms of the school's Administration of Medication Policy 2023 available on the school website. (Please tick) *

YES

Your name *

Date: *

Submit