MEDICINE RECORD/INDEMNITY FORM
 

Child’s Name ………………………………… Class ……………………………

Name of Medicine ………………………………………………………………....

How much to give (i.e. dose) …………………………………………………..….

When to be given …………………………………………………………………...

……………………………………………………………………………..…………

If the medicine is non-prescribed, i.e. calpol, etc. please give details of when your child had their last dose and how much was given ……………………………………............................………

……………………………………………………………………………………….

Any Other Instructions ……………………………………………………………..

Medicine to be left at school ………........................................................………..**

Medicine to be taken home each day i.e. antibiotics ………...............………..**

** please tick appropriate arrangement

In consideration for the Headteacher or the school’s staff agreeing to give medication to my above named child during school hours, I agree to indemnify the Headteacher and school’s staff and the Local Education Authority against all claims, costs, actions and demands whatsoever resulting from the administration of the medicine unless such claims, costs, actions or demands result out of negligence of the Headteacher, the school’s staff or the Local Education Authority.

Parent’s Signature …………………………………….. Date ………………………………

If more than one medicine is to be given, a separate form should be completed for each.