Gresford Public School

Leading the way in quality education for all

Telephone02 4938 9304

Medication consent form

Medication Consent Form (PDF 81 KB)


I:\fays files\OFFICE\Forms & notes\student


Durham Road

Gresford 2311

Ph: 49389304

Fax: 49389430


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: ________________