Surname *
Forenames *
Date of birth *
Town and Country of birth *
Academic year group on entry *
Pupil Status. *
Boarding House
(if applicable) *
Date of entry to school *
Sex *
Height (cm) *
Weight (Kgs) *
Name and address of current family doctor in UK
NHS Number if known

Boarders only

All new boarders, resident for two terms or more, will be routinely registered with the School doctor at The Avenue Surgery, Warminster, BA12 9AA. 

This leaflet provides information for all residents of EU countries* (including British citizens living in one of these countries) who may wish to use the National Health Service (NHS) while visiting England.

https://assets.publishing.service.gov.uk/media/611265058fa8f506c58e78b0/nhs_leaflet_eu_visitor_student.pdf

https://www.nhs.uk/nhs-services/visiting-or-moving-to-england/how-to-access-nhs-services-in-england-if-you-are-visiting-from-abroad/

Is your child normally resident outside the United Kingdom *
Please upload a copy of your child's EHIC card *
Please provide details of your child's personal health insurance. *

If living overseas please supply the details of your last address and family doctor in the UK, if different from above.

Last UK home address
Last UK doctor's name & address

AUTHORITY FOR MEDICAL TREATMENT

Day pupils:

No medical care will be given to any child unless parental consent is provided.

Boarders & Flexi Boarders:

MUST BE COMPLETED FOR ALL BOARDING/FLEXI BOARDING PUPILS in order for us to provide full care for your child in all circumstances.

I agree to my child receiving routine medical care and the administration of ‘Over the Counter’ medication by either the Medical or House Staff, as identified by the School protocol and agreed with the School Doctor, if he/she is taken ill in school *
If you do not consent please give your reason and instructions should your child become ill *
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 to their guardian immediately in order to protect them from infection. I acknowledge that submitting this form demonstrates my agreement to this.

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

INFECTIOUS ILLNESSES

Diarrhoea and/or vomiting 

Following an episode of diarrhoea and/or vomiting, pupils should be kept away from the 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. 

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 *

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 Adrenaline auto-injector *
Is your child's allergy life threatening? *
Please upload a full face photo of your child. A photographic identification notice will be displayed discreetly on staff notice boards *

MEDICAL CONDITIONS

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 used *
Migraines *
Please give full details of medication used *
Mental Health Issues *
Please give full details *
Skin condition *
Please give 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 SCREENING

Does your child wear glasses? *
Does your child wear contact lenses? *
When was your child's last eye examination?
Does your child have colour vision deficiency? *
Please give details *
Does your child have any hearing problems? *
Please provide details. *
Is your child receiving ongoing dental or orthodontic treatment? *
Please provide more information. *

Should a dental emergency arise no treatment will be arranged without first contacting the parents/guardians.

Does your child or has your child ever had an eating disorder *
Please provide details of the treatment they received and whether it is on-going? *
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

DO NOT SEND MEDICATION WITH YOUR CHILD TO SCHOOL UNLESS PRESCRIBED OR IS A NECESSARY OVER THE COUNTER MEDICATION REQUIRED FOR SEASONAL ALLERGIES. ALL MEDICATION WILL BE RETAINED BY THE HOUSE STAFF / SCHOOL NURSE UNTIL IT CAN BE TAKEN HOME AGAIN.

Prescribed medication must be in the original packaging with the original dispensing label attached and contain the patient information leaflet. 

All medication will be kept and administered to the individual child by the School Nurse or other responsible Staff Member.

Parents will be required to complete a medication authorisation form when bringing any other medication in to school that is not listed on this form. Please, where practically possible hand medication to the House staff/School Nurse, do not give medication to your child to hand in.

Parents of Senior School pupils should contact the School Nurse to discuss administration.

Does your child take any regular medications?
This includes inhalers. *
Condition for which medication is required. *
Name of medication/inhaler as described on the pack *
Dose and time to be given.
Does your child take multiple medications? *
Condition for which medication is required *
Name of medication/inhaler as described on the pack *
Dose and time to be given *
Condition for which medication is required *
Name of medication/inhaler as described on the pack *
Dose and time to be given. *
Condition for which medication is required *
Name of medication/inhaler as described on the pack *
Dose and time to be given *
Does your child take regular medication for ADHD?
This medication must be labelled with the child's name and a doctor's letter must be provided in English with full details of the diagnosis, the medication, strength and frequency of administration. This medication will not be administered without these details. *

The above information is, to the best of my knowledge, accurate at the time of completing the form. I give my consent to school staff administering the medication as described in this form and understand that submitting this form demonstrates that I agree to the conditions above.

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 completing this form *
Email address of parent /guardian completing the form *
Date *

Send me a copy of this form

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