LC Exchange Guide+School Toolkit - Flipbook - Page 31
Sample medical form
continued
Consent & Agreements
• I consent to my child attending [name and dates of trip here]
• I consent to my child receiving any regular medication as detailed above.
• I consent to my child receiving any emergency medical, dental or surgical treatment including anaesthetic or blood
transfusion as considered necessary by a suitably qualified medical professional. I would be informed as soon as possible in
this situation.
• I will ensure my child provides two sets of medication if necessary, for example, EpiPens, one to be carried by the
teacher/host family and one to be carried by the child
Name of Parent/Guardian:
Signature:
Date:
IF APPLICABLE for pupils with specific medical needs
I confirm that [name of child] is able to administer their own medication [please specify] every [specific regularity of
medication being taken] or in the case of an emergency.
Signature of Parent/Guardian:
Date:
I confirm that I am able to administer my own medication [please specify] every [specific regularity of medication being
taken] or in the case of an emergency.
Signature of student:
Date:
OR
I give permission for [member of staff with suitable training] to administer medication to [name of child] in the case of an
emergency or as part of their medical routine every [specify regularity of medication being taken].
Signature of Parent/Guardian:
Date:
How-to Manual for School Exchanges
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