St Cuthbert's - Pupil Medical and Welfare Form

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We would like to give you this opportunity to update your contact details for your child that is held in school. Please complete the form below. It is imperative that we hold an accurate address and telephone number for your children in case of accident or emergency. Please help us maintain our records by returning this form to us as soon as possible.

Please complete a separate form for each child.

Surname of Child *

Forename of Child *

Class *

2YO

Date of Birth *

Home Address *

Postcode *

Home Telephone Number *

Email Address *

How would you describe your Child's ethnicity? – We require this information for LEA returns and DFE returns. *

What is your child’s religion? *

What is your child’s Home Language? *

Please put a tick by the method of transport which is applicable to you *

Walk to School

Car

Bus/Train

Please put a tick by the meal arrangements which apply to your child *

Paid school meals

Free school meals

Packed lunch

Packed lunch (but entitled to free school meals)

If required to complete school work from home, does your child have access to a suitable Internet connected digital device (e.g. computer, laptop, iPad, tablet, etc) *

Yes

Emergency Contact Name and Relationship to Child (1) *

Emergency Contact Number (1) *

Emergency Contact Name and Relationship to Child (2) *

Emergency Contact Number (2) *

Emergency Contact Name and Relationship to Child (3)

Emergency Contact Number (3)

Emergency Contact Name and Relationship to Child (4)

Emergency Contact Number (4)

Emergency Contact Name and Relationship to Child (5)

Emergency Contact Number (5)

Emergency Contact Name and Relationship to Child (6)

Emergency Contact Number (6)

Name and Address of Family Doctor *

Telephone of Doctor *

Please tick those that apply to your child *

Wears glasses

Hearing problems

Physical difficulties

Eczema

Asthma

None of the above

Required

If yes to Asthma, please provide information.

Inhaler required? Which type of inhaler, dosage, times given, needed before exercise? Please send a spare inhaler into school clearly labelled with your child’s name, dose and time taken so that it is always available. Your child will be supervised taking his/her inhaler.

Yes

Clear selection

Does you child have any allergies – please state *

Does your child have an epipen? If yes, please send a spare epipen into school clearly labelled with your child’s name and type of allergy *

Yes

Any other medical issues *

Medicines? If at any time medicine needs to be administered to your child during school hours, this can be done, but only if it is prescribed by a GP or the hospital. The medicine needs to be in its original container, clearly labelled with child’s name, class, dose and time to be taken. SLT or First Aiders will administer the medication. By signing this form you are giving permission for the school to administer medicine. *

I give my child permission to walk home after school on their own. *

Yes

I give my child permission to walk home on their own after school if they have taken part in an Extra Curricular Club. *

Yes

I give permission for my child’s photograph to be used online and on social media. *

Yes

I give permission for this information will be used for extended school (e.g. breakfast club, after school club, etc) *

Yes

I have reviewed and agree to the Home-School Agreement, which is available on the school website *

Yes

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