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Medical Form
Please inform us if your child has or develops any medical conditions so we can record it in your child's records
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* Indicates required question
Email
*
Your email
Child's name
*
Your answer
Does your child have any of the following:
Asthma or bronchitis
*
Yes
No
Heart condition
*
Yes
No
Fits, fainting or blackouts
*
Yes
No
Severe headaches
*
Yes
No
Diabetes
*
Yes
No
Allergies to any known medication
*
Yes
No
Any other allergies
*
Yes
No
Other illness or disability
*
Yes
No
Any condition that could be affected by physical activity?
*
Yes
No
If the answer to any of these questions was YES, please give details
Your answer
Does your child take any regular medication? If YES, please give details
Your answer
Has your child been receiving medical or surgical treatment of any kind from either their doctor or the hospital? If YES, please give details
Your answer
Has your child ever been given specific medical advice to follow in emergencies? If YES, please give details, including name and dosage of any medication.
Your answer
Parent consent
I confirm that my child is in good health and is able to take part in all activities.
*
Yes
No
In the event of an accident or illness, I consent to any necessary medical treatment.
*
Yes
No
A copy of your responses will be emailed to the address you provided.
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