Andri Nicolaou
Child protection Designated Lead
Child’s Name _________________________
Medication to be Administered _________________________
Expiry date of medicine _________________________
Under what circumstances, (as per doctor’s instructions on the container or in specificcircumstances _________________________
____________________________________________________________________
Level of dosage _________________________
Frequency of dosage _________________________
I confirm that the medication supplied is in its original container and request that it is given to the child named, as per instructions above.
Signed _________________________ (Parent or carer of the child)
Print Name: _________________________
Dated ________________