Student Medical Information Form
Student Information
Student's Name
*
First Name
Last Name
Date of Birth
*
-
Day
-
Month
Year
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Year Group
*
Please Select
ELS
FS1
FS2
Y1
Y2
Y3
Y4
Y5
Y6
Y7
Y8
Y9
Y10
Y11
Y12
Y13
Emergency Contact Details
Contact Person
*
First Name
Last Name
Relationship to child
*
Home phone
*
Format: (000) 000-0000.
Mobile phone
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Medical Details
Health Insurance Provider
*
Address of Provider
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Policy number or plan
*
Family Doctor
Doctor's Name
*
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact number
*
Format: (000) 000-0000.
Pre-existing medical, social or emotional conditions you would like us to be aware of?
*
Yes
No
Details
Regular medication?
*
Yes
No
Details
Allergy sufferer?
*
Yes
No
Details
I/we give permission for our child to be given medication for minor conditions such as headaches, sore throats, travel sickness, etc. should my child request it.
Yes
No
List here any exceptions i.e. medication that you know your child is allergic to or is otherwise
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Special Dietary Requirements
Does your child have any special dietary requirements? e.g. vegetarian
Yes
No
Details
Additional Information for International Trips Only
Nationality as stated on passport
Passport No
Full Name on Passport
First Name
Middle Name
Last Name
VISA no(If applicable)
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General Declaration
In signing this form, I give permission for my son/daughter to participate in all activities relating to the school programme (including at clubs, field trips and ski trips, details of which may be forwarded to me at a later date). I will attach any exceptions in writing on a separate piece of paper here and I acknowledge that exemption may only be possible with proof of a medical certificate.
*
Yes
No
Separate details to be attached
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I hereby give permission to school staff to authorize on my behalf any emergency medical care (including surgery) which, on the recommendation of qualified medical personnel, may be deemed necessary. In such circumstances, I understand that school staff or their agents will seek to advise me at the earliest possible convenience.
*
Yes
No
I authorise that my child may have periods of unsupervised free time during off-site trips, as deemed reasonable and appropriate by school staff. Details of these may be forwarded to me by trip organisers on my request.
*
Yes
No
Parent or Guardian
*
First Name
Last Name
Date
*
-
Day
-
Month
Year
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Signature of Parent or Guardian (valid as paper and pen signature)
*
Enter the message as it's shown
*
Submit
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