Consent to Administer Medication

Student Name Student Name First Last
Class
Referring Doctor
PARENT/GUARDIAN PERMISSION

PARENT/GUARDIAN PERMISSION I request Calvary Christian College First Aid staff to administer the following medication to the above named child, according to the instructions provided on the medication label as prescribed by an authorised Health Practitioner. (PLEASE NOTE: verbal instructions from the parent or a pharmacy label will not be sufficient).
Name of Medication
Dosage to be Administered
Time/s to be Administered
Expiry Date of Medication Expiry Date of Medication / DD / MM YYYY
Is the medication to be picked up at the end of the school day?

Is the medication to be picked up at the end of the school day? Yes No
Is unused or expired medication to be returned to the parent/guardian?
(PLEASE NOTE: under no circumstance will a student be given expired medication)

Is unused or expired medication to be returned to the parent/guardian?
(PLEASE NOTE: under no circumstance will a student be given expired medication) Yes No
For Asthmatics Only
Can your child self-administer Ventolin:

For Asthmatics Only
Can your child self-administer Ventolin: Yes No
If yes your child can self-administer Ventolin: confidently competently and safely administer their own medication following infection control guidelines, follow their timetable for administering medication (where it is required at particular times), demonstrate practices of secure storage of medication when that medication may be potentially harmful to other students, safely dispose of sharps equipment where relevant, ensure their medication is in-date, be assured other students who are in the proximity can behave appropriately to maintain a safe and respectful environment for the student self-administering.
In the case of short-term medication (e.g. antibiotics, ear drops, cough mixture) this form is valid until the course is complete.

In the case of long-term medication (e.g. pain medication, Ventolin, anti-histamine) this form is
valid for one school year or until medication expires.

In the case of short-term medication (e.g. antibiotics, ear drops, cough mixture) this form is valid until the course is complete.

In the case of long-term medication (e.g. pain medication, Ventolin, anti-histamine) this form is
valid for one school year or until medication expires. I the parent/guardian of the named student agree with the above statements.
Parent/Guardian Name Parent/Guardian Name First Last
Email
Date Date / DD / MM YYYY
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