Medical Form

Parent's FULL Name

Child's FULL Name

Child's Date of Birth

Doctor Surgery Name

Doctor Address and Postcode

Doctor's Telephone Number

Does your child or the child in your care have any known medical problems or additional needs?

Please detail any medical needs your child has/medication taken: (please provide full details, if medication is needed an additional medication consent form will need to be completed)

Does your child have any known allergies? If so, please list.

Does your child have any dietary requirements? If so, please list

Any other information relevant to your child’s health

Parent/Carer emergency contact names and telephone numbers:

In the event that my child is involved in a serious accident I expect to be contacted immediately on the above telephone numbers.

In the event that my child requires immediate medical treatment before I can get to the hospital I hereby authorise the staff member present to consent to any emergency medical treatment necessary to ensure the health and safety of my child on my behalf.

Your Signature

07912 548 965

Medical Form

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