110 MIMOSA ROAD, BOSSLEY PARK, 2176 PHONE: 9604-3877 FAX: 9609-4988 ABN 82 780 246 140

NOTIFICATION AND REQUEST BY PARENT / GUARDIAN FOR THE ADMINISTRATION OF MEDICATION DURING SCHOOL HOURS

To be completed by Parent or Guardian I request that my child: ____________________________________________________________________ Full Name of Student Be allowed to take medication at school according to instructions from: _______________________________________________________________________________________ Full Name of Prescribing Doctor _______________________________________________________________________________________ Address and Phone Number of Prescribing Doctor The medication has been prescribed for the following reason: _______________________________________________________________________________________ Name of Medication: ______________________________________________________________________ Dosage: ____________________________

Time to be taken at: _______________________________

Period of time for medication to be taken: ______________________________________________________ I accept and agree to observe the conditions imposed by the school and understand and agree that it is my responsibility to inform the Principal of any changes involving the administration of the medicine.

Signed _____________________________________ Parent/Guardian

Date: ___________________