Medication Consent Form (PDF 81 KB)
I:\fays files\OFFICE\Forms & notes\student
GRESFORD PUBLIC SCHOOL
Durham Road
Gresford 2311
Ph: 49389304
Fax: 49389430
CONSENT TO DISPENSE MEDICINES (Short Term/Long Term)
I, _________________________________________ (Parent/Guardian)
request my son/daughter ________________________________________ _____________
(Full Name) (Class)
to be given _____________________________________________________ at ______________________________________
(Name of Medication) (times)
in dosages of ____________________________________________from _____________________to ____________________
(ml or tablets) (Date) (Date)
I can be contacted in an emergency at ________________________. In an emergency requiring medication attention, I authorise
the school to contact: _________________________________ ______________________________ ________________
(Doctor) (Address) (Phone)
and/or to organise transportation to the local hospital.
The following conditions will apply:
1. It is your responsibility to provide the medication and equipment for its administration, and to ensure its immediate replenishment after use, or when it requires replacement.
2. The school will render whatever aid is necessary to administer the medication, but it is understood that this aid is that of a lay person, without medical training.
3. In consideration of the members of staff of Gresford Public School administering medication to my son/daughter ___________________________ as requested by me I hereby indemnify and keep indemnified The Department of Education & Training and its officers, servants and agents against all actions, suits, claims, demands, proceeedings,losses,damages, compensation, costs, charges and any expenses whatsoever in respect of any personal injury or of any infringement,disturbance or destruction of any rights of any person including myself and my son/daughter ______________________
arising directly or indirectly out of the aforementioned administration of medication.
I agree to the above conditions and also agree to inform the Principal, in writing, of any change in the nature, dosage or frequency of the medication required by ______________________________ (first name).
Parent/Guardian Signature: __________________________________ Date: ________________