Administration of Medication Form 2015 - Bunscoil Buachaillí Réalt na Mara

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Administration of Medication Form 2015

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Request for Administration of Medication


(Use  BLOCK CAPITALS only)

Name of Child _____________________   Class_________________  

Class Teacher____________________       Date______________________

Medical Condition_____________________________

Name of Medication____________________________

Prescribed Medication Dose_________________________________________


Circumstances in which Medication is to be given









Procedure for Administration of Medication_









What to avoid when treating the child









Name of person(s) who has/have agreed to administer this medication to ___________________(child’s name)



_____________________________________________________________________


Contact numbers: Parent (Guardian)   __________________________  Parent(guardian)
_____________________________________________________________________

Other care giver in emergency situation and phone numbers

______________________________________________________

Family doctor and phone number_________________________________________________

_____________________________________________________

I hereby agree to the above procedures and indemnify the Board of Management, and staff, of Bunscoil Buachaillí Réalt na Mara, Donacarney, in respect of any liability that may arise regarding the administration of prescribed medicine to my son__________________________________________________________(name)

I have read and understood the school`s policy on the administration of medication.



Signed____________________ (Parent/Guardian)


Date__________________________

 
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