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ANNEX D SAMPLE FORM - STUDENTS WITH MEDICATION NEEDS
As outlined in section 4.5.11, colleges may wish the student to provide written confirmation of their medication requirements and procedures to be followed in an emergency.
The following information is likely to be most helpful to the college.
Name:
Programme of Study:
Address:
Condition or illness:
Name of medicine:
Procedures to be followed in an emergency:
Name and daytime telephone number of person to be contacted in an emergency:
Relationship to student:
Declaration:
I understand that the college has put in place a reasonable adjustment to allow my medication to be administered by a health professional, parent, carer or by myself. I understand that the information given by me in this form will be held in the strictest confidence by the college. I have given my consent to the following people administering medication to me.
Names of authorised individuals:
Signed
Date
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