Parents: Medicines

Parental Agreement for St. Ambrose Preparatory School to Administer Medicine

The school will not give your child medicine unless you complete and sign this form.

Date:

Child’s Name:

Class:

Name and strength of medicine:

Expiry date:

Dose to be given:

Time to be given:

Any other instructions?

The above information is, to the best of my knowledge, accurate at the time of writing and I give consent to the school to administer medicine in accordance with the school’s policy. I will inform the school immediately, in writing, if there is any change in dosage or frequency of the medication or if the medicine is stopped.

Print name: _________________________________

Signature: _________________________________

Please note a separate form needs to be completed if more than one medicine needs to be given.