Person Completing this Form *

First Name

Last Name

Child's Name *

First Name

Last Name

Emergency Contact Number & Name: *

(###)

###

####

Secondary Emergency Contact Number & Name: *

(###)

###

####

Are they able to Self-Administer? *

Yes

No

Permission - Tick to Give Consent *

The above information is, to the best of my knowledge, accurate at the time of writing and I give consent to School/Setting Staff adminstering medicine in accordance with the school/setting policy. I will inform the setting if there are any changes

Permission - Tick to Give Consent *

Inline with Setting Policy, we will always attempt to make contact with Primary and Secondary Emergency Contacts.

I give permission for the Setting to take the neccessary Emergency First Aid Steps required, such as calling an Ambulance/Taking to Hospital if they are unable to get Hold of either the Primary or Secondary Emergency Contact Number