Medical & Activity Details

Student Details

Family name

First name

Current doctor contact details

Medical History including dates

Current medical conditions

Medication currently being taken

Allergies (including medical, food, stings, animals)

Family history of medical issues (e.g. diabetes, epilepsy)

Medical/Dental insurance details

Email address

Vaccinations

Please ensure your child has received all vaccinations currently recommended in your home country.
Indicate which of these vaccinations your child has received and provide dates:

BCG

Polio

Hib, Diphtheria, Tetanus, Whooping Cough

Measles, Mumps, Rubella

Typhoid

Hepatitis A x2

Hepatitis B x3 and Booster

Meningitis

Medical Treatment

I give permission:
1. For my child to be given First Aid treatment in the event of injury;

2. For my child to be given appropriate over the counter medication in accordance with the School Doctor’s instructions or a qualified medical practitioner on usage;

3. For my child to be given all emergency medical or dental treatment including vaccinations, general or local anaesthetic, surgery or blood transfusions which, in the opinion of a qualified doctor, are necessary for my child’s safety and wellbeing under the National Health Service or privately if necessary;

Transport

I give permission:
1. For my child to travel by any form public transport and/or in a motor vehicle driven by a responsible adult who is duly licensed and insured to drive that type of vehicle;

Activities

I give permission

1. For my child to swim under adult supervision;

2. For my child to take part in water sports, fairground rides, outdoor activities under adult supervision;

3. Please state any specific activities for which you do not give permission for your child to take part in;

Other details

Please state any further medical or dietary information which applies to your child;

Please state any psychological or other conditions which may affect your child;

Please state any other details about your child to ensure their welfare whilst in the care of Regent Guardians;

Parent signature

Parent Name