Personal Details
| Setting | |
| Name of Child | |
| Date of Birth |
| Name of Doctor | |
| Address |
|
| Phone Number |
A parental permission form must be completed for each type of medication being taken by the child
I confirm that my child ……………………..……requires the following medicine(s) and that I give permission that it /they can be administered by a non-medically qualified staff member of Taynuilt ELC
………………………………………………………………………………………………………………………………….…..…
I will also inform the setting immediately of any changes in medication and will provide an appropriately labelled supply.
Signature …………………………………………… Date ………………..….…..….
Print Name …………………………………………………………………………….…
Home Address ………………………………………………………………..………….
…………………………………………………… Telephone No. ……………………
Emergency Contact Person (if different from above) ……………………..………
Relationship ………………………………………………………………………..……
Telephone No. ………………………………………………………………….…..…..
Details of Medication
| type of illness | |
| name of medication (as stated on label) | |
| type of medication
eg tablets, syrup |
|
| dosage instructions
eg how often, when and any other relevant information |
|
Parent’s signature confirming medication and dosage
Signed: ……………………………………………………………..…………………
Print Name: ………………………… Date: …………………………………
