VBS Catchment Area
Teach me to follow you,
and I will obey your truth
Healthcare & Medication Form
Only essential, prescribed medication may be brought to VBS. VBS Staff are under no obligation to administer medication; this must be agreed on an individual basis. It is the responsibility of the Parent / Guardian to provide full and accurate information, to label medication and to drop off / collect medication each day. By completing this form, you are indicating that you have read and agree to these terms.
Date of Birth:
Medical Condition(s) / Allergies:
Describe medical needs:
Please give details of child’s symptoms, triggers, signs, treatments, facilities, equipment or devices, environmental issues, etc.
Will your child be bringing medication to VBS?
Name of Prescribed Medication(s):
Instructions for use:
Please include dosage amounts and times, if applicable. The information leaflet supplied with the medication should preferably be brought to VBS and kept with the medication. (This section must be completed, even if the child is self-administering and/or looking after medication him/herself.)
Administration of Medication:
Self-administered with adult supervision
Administered by an adult
Any special storage instructions, e.g. temperature:
Where is the medication to be kept? (See guidelines below)
Child's Tent *
First Aid Tent **
Carried by the child ***
* Emergency medication, e.g inhalers, Epi-pens
** Non-emergency medication, e.g. anti-biotics
*** Older children may carry their own medication, with VBS Nurse's approval.
Medication must not be left unattended; children are responsible for handing it to an adult for safe-keeping if at any time they do not wish to take it with them, i.e. break times.
Specific support for the child’s physical / social / emotional needs:
Describe what constitutes an emergency, and the actions to take if this occurs:
Name of Next of Kin:
Relationship to Child:
Primary Emergency Contact Number:
Alternative Emergency Contact Number:
I confirm that the above information is correct to the best of my knowledge and belief, and I will notify VBS of any changes.
(When signing this form electronically, by entering YOUR NAME and TODAY'S DATE below, you agree your electronic signature is the legal equivalent of your written signature.)
If your form fails to submit, please check that all compulsory fields (marked *) have been completed.
VBS Catchment Area