Administration of Medicines/Monitoring of Medical Condition

Child’s Name: __________________                                      ____



Date of Birth_________________________

Emergency Contacts:

1) Name: ________________________

Phone: __________________________
2) Name: ________________________

Phone: __________________________
3) Name: ________________________

Phone: __________________________
4) Name: ________________________

Phone: __________________________

Child’s Doctor: ______________________

Phone: _________________                       _

Diagnosed condition: ___________________________________

Prescription details: ____________________________________



Is the child to be responsible for taking the prescription him/herself?

Description of medical condition:




What action is  required: ____________________________________                                                                                           _______


I/we request that the board of management authorise the taking of prescription medicine during the school day as it is absolutely necessary for the continued well being of my/our child. I/we understand that the school has no facilities for the safe storage of prescription medicines and that the prescribed amounts be brought in daily. I/we understand that we must inform the school/teacher of any changes of medicine/dose in writing and that we must inform the teacher each year of the prescription/medical condition. I/we understand that no school personnel have any medical training and we indemnify the board from any liability that may arise from the administration of the medication.


Parent/Guardian _________________________ Date____________________                     _____
Parent/Guardian _________________________ Date________________________                      _

This policy was reviewed on 23rd February 2012  and will be reviewed again on                                     .

Signed                                                 Date                                      

Rev Jane Galbraith  (Chairperson)