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Please fill in the form below to inform the school about any medical conditions. If you prefer to do this offline please see our downloads page for a printable version of this form.

Note: Fields marked with a '*' are required.

 

Pupils Details
Surname: *		Forenames: *
Date of Birth: *		Place of Birth: *
Nationality: *
Immunisation Details
Please give dates of immunisation against the following:
Diptheria		MCC (Meningitis)
Tetanus		BCG
Whooping cough		MMR or Separate
Hib		Vaccines - Please list
Polio
Medical History
Please give details of existing conditions such as asthma, eczema, hay fever, hearing/sight problems, grommets, fits or convulsions, hyperactivity, behaviour problems.
Please give details of: Allergies or adverse reactions (including medication).
Psychological problems/special needs.
Surgery or medical investigations.
Has your son/daughter lived overseas? If so, has there been any contact with any tropical diseases?
Is there any feature of your son/daughter’s physical or mental health which you feel the school should be aware of?
Is there any reason why your child should not take part in all normal school games and activities? *		Yes No
If yes, please give details.
Is your child receiving any regular medical treatment? *		Yes No
If yes, please give details. It may also be helpful to have a letter from the health professional giving the treatment, outlining your child’s conditions and its implications.
Name address and telephone number of General Practitioner:
Emergencies
The school keeps a small stock of medicines, creams, etc, all of which are non-prescription remedies. If you are happy for them to do so, authorised school staff will administer these as is necessary and appropriate, according to the stated dose. Please tick to acknowledge the statement below to give permission for this.
I give my permission for authorised school staff to administer non-prescription medicines as is thought appropriate and necessary.
In an emergency situation we would always endeavour to make contact with parents or their nominated person in their absence. It is, however, possible that a situation may arise when we need to make urgent decisions on your behalf and we require your permission to do so.
I/we agree that in emergency where urgent medical/dental/surgical treatment is required and a parent or nominated person cannot be contacted, the school is empowered to give permission for any such treatment.
Name of parent or guardian: *
Address: *
Telephone no: *
Date: *