Consent to Administer Medication

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In order for Calvary Christian College staff to administer medication, this form MUST be completed.
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Calvary Christian College staff will NOT be able to administer medication:
- based on verbal instructions from the parent
- based on instructions on a pharmacy label alone
- when medication is expired

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Name of Student: Name of Student: First Last
Year Level
MEDICATION DETAILS
Referring Doctor
Name of Medication
Dosage to be Administered
Time/s to be Administered
Expiry Date of Medication Expiry Date of Medication / DD / MM YYYY

PLEASE NOTE!
Under NO circumstances will a student be given expired medication
Will you be required to provide more medication throughout the year?

Will you be required to provide more medication throughout the year? Yes No
Is the medication to be picked up at the end of each school day?

Is the medication to be picked up at the end of each school day? Yes No
Is unused or expired medication to be returned to the parent/guardian?

Is unused or expired medication to be returned to the parent/guardian? Yes No
ASTHMATIC STUDENTS
Your child can self-administer Ventolin if they can:

*Confidently, competently and safely administer their own medication
*Follow 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.
Can your child self-administer Ventolin?

Can your child self-administer Ventolin? Yes No N/A
PERIOD OF VALIDITY
Short Term Medication:

*This form will be valid until the course is complete of until medication expires, whichever comes first.
*(eg: antibiotics, ear drops, cough mixture)
Long Term Medication:

*This form will be valid for one school year, with the understanding that more medication will be provided throughout the year, and only medication with a valid expiry date will be administered.
*(eg: Ritalin, pain medication, Ventolin, anaphylaxis medication)
How long will this medication be required for?

How long will this medication be required for? Short Term Long Term
AUTHORISATION
Parent / Guardian Permission:

By signing this form I hereby authorise Calvary Christian College staff to administer the above medication to the above named student, according to the instructions provided on the medication label, as prescribed by an authorised Health Practitioner
I have read, understood, agree and will abide by the terms of this Consent to Administer Form:

I have read, understood, agree and will abide by the terms of this Consent to Administer Form: Yes
Parent/Guardian Name Parent/Guardian Name First Last
Email
Date Date / DD / MM YYYY
Draw your signature into the box below.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.

Consent to Administer Medication

Consent to Administer Medication

MEDICATION DETAILS

ASTHMATIC STUDENTS

Your child can self-administer Ventolin if they can:

PERIOD OF VALIDITY

Short Term Medication:

Long Term Medication:

AUTHORISATION

Parent / Guardian Permission: