PUPIL HEALTH FORM - Balcombe School
If any of the following health facts or concerns apply please complete and submit this form.  DO NOT COMPLETE FORM IF THERE ARE NO HEALTH ISSUES TO REPORT.
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Name of Child *
Date of Birth
Class - if registered
Medical Details
MEDICATION
Give details of any medication your child is taking for conditions noted above.
CONDITION/CONCERN *
Has your child been diagnosed with or are you concerned about any of the following
MEDICATION AT SCHOOL *
Does your child require medication to be kept/administered at school?  
Required
TYPE OF MEDICATION
If you answered yes above, please list medication and dosage and give clear instructions below.  Only in-date medication prescribed to the child by a doctor will be administered:  If your child requires medication for Asthma you will be required to complete a separate Asthma Record.
GENERAL HEALTH CONCERNS
Please note any other concerns you have.  This medical information must be kept up to date by the parent who must advise the school of any changes.
Name of Person completing this form
Your relationship to the child
Date completed and submitted
Submit
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