Surname *
Forenames *
Date of Birth *
Date of entry to school *
Please choose which year group your child will be entering. *
Sex *
Height (cm) *
Weight (kg) *
Town and Country of birth
Name and address of current family doctor in UK *
NHS Number if known

AUTHORITY FOR MEDICAL TREATMENT

I agree to my child receiving routine medical care and understand that if my child should require "over the counter" medication I will be contacted first.
I acknowledge that submitting this form demonstrates my agreement to this *
If you do not consent please give your reason and instructions should your child require medical care *
Name of parent/guardian completing this form *
Date *

CONSENT TO EMERGENCY HOSPITAL TREATMENT

An emergency may arise which makes it imperative for a child to receive treatment without delay. In these circumstances, the hospital will always attempt to contact the parents immediately whenever possible and ask for verbal consent before an anaesthetic or treatment is administered.

I give my consent for the accompanying staff member to act in loco parentis and provide informed consent for emergency treatment identified by the hospital as being essential for the welfare of my child should you be unable to contact myself or any emergency contacts held by Warminster School. I acknowledge that submitting this form demonstrates my agreement to this *
If you do not consent please give your reason and instructions should your child become ill and require emergency treatment *
Name of parent/guardian completing this form *
Date *

IMMUNISATIONS

Your child’s immunisations MUST comply with the UK Childhood Immunisations Schedule which can be found on the following website www.nhs.uk/Conditions/vaccinations/Pages/vaccination-schedule-age-checklist.aspx

I am aware that if my child is not immunised in accordance with the United Kingdom schedule they will be regarded as unprotected against certain infectious diseases and therefore at risk. If there is an outbreak of an infectious disease in the school my child will be sent home immediately in order to protect them from infection. I acknowledge that submitting this form demonstrates my agreement to this

Name of parent/guardian *
Date *
Please tick to indicate the the following immunisations are up to date. Tick all that apply *

ACUTE MEDICAL CONDITION/ILLNESS

Has your child been treated by a doctor had any vaccinations or suffered from any particular health problem during the past year? *
Please provide further details and include any ongoing treatment. *

INFECTIOUS ILLNESSES

Diarrhoea and/or vomiting

Following an episode of diarrhoea and/or vomiting, pupils should be kept away from school for a 48 hour period after the symptoms have ceased. The viruses that cause gastro-intestinal symptoms can remain infectious for 48 hours after the symptoms have resolved and therefore cross-infection remains a risk factor.

Temperature or fever

If your child's temperature is raised above 37.6 °c they should remain off school until they have had a normal temperature for 24 hours without the assistance of medication.

COVID-19

Please follow current UK Government guidelines regarding symptoms, testing and isolation.

ALLERGIES

Does your child have an allergy *
Please provide full details and treatment for the allergy *
Does your child carry an Adrenaline auto-injector? *
Please provide details of the Adrenaline auto-injector *
Please upload a full face photo of your child. A photographic identification notice will be displayed discreetly on staff notice boards *

MEDICAL CONDITIONS

If a child has a chronic illness it is recommended that they have an Individual Healthcare Plan (IHP) developed between the child, parents and the School. This will ensure that the child is provided with the most appropriate care and support during his/her time at the School. The School Nurse will contact the parents of pupils she feels may require an Individual Healthcare Plan.

Does your child have or has ever suffered from any of the following?

Asthma *
Please give further details including names of inhalers used *
The school holds a central reliever inhaler and spacer for use in an emergency. The emergency Salbutamol inhaler (blue) will only be used by children, for whom parental consent for use of the emergency inhaler has been given, who have either been diagnosed with asthma and prescribed an inhaler, or who have been prescribed an inhaler as reliever medication. The inhaler can be used if the pupil's inhaler is not available.
Do you give permission for your child to use the emergency inhaler? *


Blood disorders *
Please give full details *
Bone/Joint problems *
Please give full details *
COVID-19 *
Please give dates *
Diabetes *
Please give full details *
Epilepsy/Convulsions *
Please give full details *
Hayfever *
Please give full details of medication normally used *
Mental Health Issues *
Please give full details *
Skin condition *
Please provide full details of treatment. *
Has your child suffered from any other illnesses, operations or accidents that we should be aware of? *
Please give full details *

FAMILY MEDICAL HISTORY

Do any members of the family suffer from any serious health conditions?

*
Please give full details *

HEALTH SCREEN

Does your child wear glasses? *
When was your child's last eye examination?
Does your child have colour vision deficiency? *
Please provide details *
Does your child have any hearing problems? *
Please provide details. *
Does your child have any eating issues that we need to be aware of? *
Please provide full details *
Does your child require a special diet for medical, Religious or other reasons? *
Please provide full details of dietary requirements *
Please upload a full face photo of your child. A photographic identification notice will be displayed discreetly on staff notice boards *

MEDICATION

Prescribed medication: Must be in the original packaging with a clear and legible label and contain the patient information leaflet. 

Over-the-counter (Homely Remedies) Medication: We will contact you directly for verbal consent if your child requires over the counter medication i.e. pain relief. You will be required to sign a written consent when you collect your child from school.

You will be required to sign a consent form for the administration of medication. All medication will be kept and administered to the individual child by the School Nurse/other responsible staff member.

Does your child take any regular medications, including inhalers? *
Please provide full details. *

PASTORAL INFORMATION

Please use the space below to provide details regarding any issue that you feel may affect your child’s emotional, physical or mental health. It is helpful for us to know whether a child was born prematurely or had difficulties at birth, as this can affect their development and learning skills. Also, if there are any family issues i.e., long term ill health, step-families, adoption or recent deaths, it is always beneficial for us to be made aware of these situations so we are able to provide holistic and encompassing support for your child.

I would like to share information *
Please provide as much detail as possible. *

If you feel there is information that you would prefer only the School Nurse to be aware of please indicate below.

Please contact me

DECLARATION

Information provided in this form will be shared with the academic staff if the School Nurse feels that it is appropriate to in supporting the health and well-being of your child. It is important that chronic medical conditions, allergies or any other health concerns, are shared with the academic staff so they can actively support your child and provide appropriate care.

I acknowledge this information and confirm that all of the information submitted in this form is true and accurate.

Name of parent/guardian *
Email address of parent / guardian completing this form. *
Date *


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