CONSENT FOR THE ADMINISTRATION OF MEDICINES FORM

Child’s Name:

D.O.B

Prescribed by:

Medicine Prescribed:

Dosage Required (If liquid - amount)

Long term/ short term (if long term reasons why)

NB Please notifies staff of any dosage of medicine given before coming to the nursery.

Name of medicine___________________________________________________

Date_________Time ___________Dosage__________ Parents Signature_________

I give permission for authorised staff at Watcombe Children’s Centre Nursery to give my child the above medication prescribed.

Signed: _______________________________ Date: _____________

Print Name: ___________________________________________________

Relationship to child: ___________________________________________

Date

Time

Dosage

Administered by

Witness by

Parents signature

Date