Medical Form The contents of this form will be treated in the strictest confidence.Please complete this form as Gayhurst School requires medical information for the safe care/treatment of your child whilst at school. This form must be re-submitted at the beginning of every academic school year AND if your child’s information changes.BASIC INFORMATIONName of child(Required) First Last Date of birth(Required)Year Group (in September 2023)(Required)NurseryReceptionYear 1Year 2Year 3Year 4Year 5Year 6Does your child wear glasses?(Required)YesNoIs your child left or right handed?(Required)LeftRightAmbidextrousNHS Number(Required)Does your child have dental conditions that the school should be aware of (caps etc.)Does your child have an eye condition that the school should be aware of?Does your child have any hearing difficulties that the school should be aware of?Does your child suffer from travel sickness(Required)YesNoWhat medication do they take for their travel sicknessIMMUNISATIONSDiptheria, tetanus, whooping cough, polioYesNoDatePneumoccoccal infectionYesNoDateHaemophilius influenza type B (Hib)YesNoDateMeasles, mumps, rubellaYesNoDateMeningitis CYesNoDatePlease gives details and dates of any other immunisations given (including those for travel)Name of doctor(Required) DrMissMrMrsMsProf.Rev. Prefix Last Address of surgery (including postcode)(Required)Telephone number of surgery(Required)OTHER DETAILSDoes your child have any special dietary requirementsYesNoWhat are your child's dietary requirementsDoes your child have any allergiesYesNoIf your child has allergies please tell us what they are (including food)What medication is required for your child's allergiesDoes your child have any medical conditions?YesNoIf your child has a medical condition please tell us what it isWhat medication is required for your child's medical conditionDoes your child have an inhaler?YesNoDoes your child have an auto-injector (eg Epi-pen)YesNoCONSENT TO MEDICAL TREATMENTI/We give consent for my/our child receiving all general health care and first aid services provided at the school under the supervision of qualified First Aiders. Please note in Years 3 to 6 we will only give non-prescribed medication (eg painkillers) when verbal permission has been given by a Parent/Guardian. I/We authorise the Head or an authorised deputy acting on the Head’s behalf to consent, on the advice of an appropriately qualified medical specialist, to my/our child receiving emergency medical treatment, including general anaesthetic and surgical procedure if the school is unable to contact me/us in time.Completing your details is giving your consent as above.Name of Parent/Guardian 1(Required) DrMissMrMrsMsProf.Rev. Prefix First Last Relationship to child(Required)Date(Required)Mobile number(Required)Work numberHome numberParent/Guardian 1 email(Required) Name of Parent/Guardian 2 DrMissMrMrsMsProf.Rev. Prefix First Last Relationship to childDateParent/Guardian 2 Mobile numberParent/Guardian 2 Work numberParent/Guardian 2 Home numberParent/Guardian 2 EmailEMERGENCY CONTACT (different to above)Name of parent/guardian 2 DrMissMrMrsMsProf.Rev. Prefix First Last Relationship to childMobile numberEmergency Contact Work numberEmergency Contact Home numberEmergency Contact Email Δ
