Administration of Medication Form - Bunscoil Buachaillí Réalt na Mara

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Administration of Medication Form

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Request for Administration of Medication


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)


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