FORM 5: Short Term 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

Class *

a pupil in Hansfield Educate Together National School hereby request the Board of Management to authorise the Class Teachers/Additional Needs Assistants to administer medication to my/our child as follows:.

Medication type: *

Medication name: *

Nature of illness (eg sore throat): *

Dates medication to be administered: FROM/TO *

Dosage/adminstration instructions: *

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 in a suitable container labelled with the child's name, class teacher, year group and emergency contact details.

This form must be completed and submitted to the school before any administration of medication is facilitated.

By submitting this form, I confirm that I 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