Permission to Give Medication Form

*Please complete the form in full and to return it with medicines to the relevant clinic/personnel
Student Name:*
Grade:*
Date of Birth:*
MM slash DD slash YYYY
Diagnosis/Reason for giving/Additional information:*
I consent for the nurse/doctor to administer the following medication to my child as directed and am aware that these details may be disclosed to ISY staff.
- I consent for the nurse/doctor to administer the following medication to my child as directed and am aware that these details may be disclosed to ISY staff.
Name of Medication*
Dose to take (mg, ml)*
Route (e.g., ear, eye, nasal, oral, or topical)*
Time to be given/frequency*
Expiry date*
MM slash DD slash YYYY
Any other instructions*
Name of Medication
Dose to take (mg, ml)
Route (e.g., ear, eye, nasal, oral, or topical)
Time to be given/frequency
Expiry date
MM slash DD slash YYYY
Any other instructions
Name of the parent/guardian:*
Parent/guardian email address:*
Contact Number:*
Date*
MM slash DD slash YYYY
Signature*