Student Medical and

Emergency Contact Form

PLEASE COMPLETE IN CAPITAL LETTERS

Child’s Name:__________________________________________________________________________________

Address:________________________________________________________________________________________

____________________________________________________________ Postcode:__________________________

Home Tel No:___________________________________________ Mobile:_________________________________

National Health Number:__________________________________________________________________________

DOCTOR DETAILS

Doctors Name:__________________________________________________________________________________

Address:________________________________________________________________________________________

____________________________________________________________

Tel No:__________________________

Do you suffer from any of the following? If you answer YES to any of the following, please explain

further in the space provided below giving details of severity, medication etc.

Chest pain brought on by physical activity?

YES / NO

Asthma, exercise-induced asthma, allergy asthma, hay fever?

YES / NO

Diabetes?

YES / NO

Migraines?

YES / NO

Epilepsy?

YES / NO

Allergies (antibiotics, peanuts, food-types etc.)?

YES/ NO

Other illnesses, disability or injury?

YES / NO

If YES to any of the above, please provide details:

___________________________________________________________________________________________________

___________________________________________________________________________________________________

___________________________________________________________________________________________________

___________________________________________________________________________________________________

Is your son/daughter being prescribed any medication at present?

YES /NO

If YES, please provide details of the medication and frequency of dosage below:

___________________________________________________________________________________________________

HEALTH AND SAFTEY INFORMATION:

Can your son / daughter swim?

YES /NO

If YES, how far (metres) is your son/daughter able to swim? _______________________________________

Does your child wear glasses/contact lenses?

YES / NO

Does your child have a hearing impairment?

YES / NO

Does your child have any physical/mobility impairments?

YES / NO

Does your child have any dietary requirements? Medical, Religious or any other reason?

YES / NO

If YES, please explain below

___________________________________________________________________________________________________

___________________________________________________________________________________________________

___________________________________________________________________________________________________

EMERGENCY CONTACT DETAILS:

EMERGENCY CONTACT 1: NEXT OF KIN

Name:________________________________________________

Relationship to child:____________________

Address:__________________________________________________________________________________________

Day Tel No:___________________________________________

Eve Tel No:_______________________________

Work Tel No:__________________________________________

Mobile:__________________________________

EMERGENCY CONTACT 2

Name:________________________________________________

Relationship to child:_____________________

Address:__________________________________________________________________________________________

Day Tel No:___________________________________________

Eve Tel No:_______________________________

Work Tel No:__________________________________________

Mobile:__________________________________

EMERGENCY PERMISSION

In the event that medical staff deem immediate treatment is essential and the delay in contacting your

son/daughter’s next of kin is likely to prejudice recovery, I authorise staff to give permission to the

doctor to undertake whatever treatment is considered necessary .

Signed:_______________________________________________________

Date:___/___/___