Admission Student Medical Form

Student's Name* Date of Birth* Class* Parent/Carer's Name*

Does your child suffer (or has suffered) from any of the following:

If you have answered yes to any of the above, please provide details, including the severity of the condition, and (if applicable) the name and dosage of any medicines.* Has your child received any vaccinations? If yes please give details below.* Has your child received any vaccination against Tetanus in the last 10 years?* Does your child take regular medication? If yes please give details below.* Is your child receiving treatment of any kind from either a doctor or a hospital? If yes please give details below.* Has your child been given specific medical advice to follow in emergencies? If yes please give details below.* Any other illness or disability? If yes please give details below.*

If your child's allergies require an adrenaline autoinjector pen at school; your child’s healthcare provider must complete and sign the following Allergy Action Plan. (Please copy and paste link below, it’s an editable form. Please, send form in pdf format when completed and signed)
https://www.bsaci.org/wp-content/uploads/2020/02/BSACIAllergyActionPlan2018NoAAI2981-2.pdf

If your child has severe Asthma that requires an inhaler at school; your child’s healthcare provider must complete the Asthma School Card as applicable. (Please copy and paste link below, it’s an editable form. Please, send form in pdf format when completed and signed)
https://www.asthma.org.uk/e5335884/globalassets/health-advice/resources/children/school_asthma_card_may22_cc_editable.pdf

If it is considered necessary, do you consent to your child being given Paracetamol? (e.g Paracetamol being administered for period cramps, headache/migraines)* If it is considered necessary, do you consent the following homeopathic remedies being administered? (Arnica tablets, Arnica ointment, Hypercal ointment, Combudoron ointment, Combudoron spray, sugar free lozenges)*

Emergency Treatment

I give consent that, in the event of an injury requiring emergency hospital treatment, and only if I can’t be contacted by the school, a representative of Michael Hall School may sign any hospital authorization in my absence. (Please note: it’s good practice to seek consent here, but in a medical emergency the school can consent on behalf of your child (on the basis of ‘loco parentis’), regardless of whether you have ticked this box.)*

Non-Parental Emergency Release

I give my consent for my child to be released to the following person(s) in the event of emergency or illness, if we cannot be contacted. They are also permitted, to give medical consent in my absence (please notice this is a mandatory safeguarding requirement so no forms will be accepted without this information, parents MUST NOT be put down as emergency contact as we would just contact them in case we are unable to contact the parents)

Please rate the following*

	Emergency Contact 1 (relationship to child)	Phone number	Emergency Contact 2 (relationship to child)	Phone number

Medical Practitioner/ GP details. Please give details of your child’s current medical GP and Clinical Specialist Team if relevant: Is there any other additional medical, personal or family information that you think the school should be aware off? If your child has any medical condition or mental wellbeing concern, please attach a copy of any relevant medical reports:

I understand that it is my responsibility to update the school with any changes to these details using the medical update form available on the school website Parent Portal or via email to [email protected] Any information given on this form is held on our management information system until your child leaves this school and is not shared with any third parties.*I confirm

Name* Date*