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Medical Information and Consent Form

The school requires you to complete all sections of this form as fully as possible. The information provided by you in this form will help us to care for your child while they are a pupil at the School.

All information on this form will be treated in confidence.

For more information about how the School may use you and your child's information contained in this form, please see our pupil privacy notice and our parent privacy notice which are enclosed with the letter of offer and published on the School website under 'Admissions'.

Child's Details*
 
Child's full name:
Date of birth:
Date of entry to Warwick School:
Child's Doctor's Details*
 
Name of child's doctor:
Address of child's doctor:
Telephone number of child's doctor:

Eyesight and Hearing

Does your child have an eyesight condition?*
Does your child have a hearing condition?*

If your child takes any medication for an eyesight or hearing condition, please provide details in the 'Medication' section of this form.

Infectious Conditions

Has your child had any of the following infectious conditions? (Please tick 'Yes' or 'No' for each):*
 YesNo
Mumps
Rubella
Chickenpox
Measles
Glandular Fever
Rheumatic Fever

If you need to provide us with further details, please do so in the 'Additional Information' section at the end of this form.

Has your child been in contact with anyone with an infectious or contagious disease? (if 'Yes', please provide details in the 'Additional Information' section at the end of this form).*

Allergies

Does your child have an allergy to any of the following?*
 YesNo
Medicine
Hay Fever
Animals
Foods
Other allergies
Does your child take any medication for an allergy?*
Has your child been prescribed an EpiPen (or other auto-injector?)*

If you answered 'Yes', please provide details in the 'Medication and Treatment' section of this form.

Other Conditions

Does your child have any of the following conditions?*
 YesNo
Asthma
Diabetes - Type 1
Diabetes - Type 2
Epilepsy
Mental Health Conditions

If your child takes any medication or receives treatment for an above named condition, please provide details in the 'Medication and Treatment' section of this form.

Immunisation

The following table lists the routine and optional vaccinations (including travel vaccinations) available for children in the United Kingdom.

Please provide date(s) of immunisation of your child where indicated or, if immunisation not carried out, please state.

Routine Vaccinations*
 Date(s) of Immunisation
5 in 1 Vaccine (Diphtheria, Tetanus, Whooping Cough, Polio, Hib)
PCV (Pneumococcal Jab)
Rotavirus
Men B (Meningococcal Jab)
Hib/Men C
MMR (Measles, Mumps, Rubella)
Children's Flu Vaccine
4 in 1 Pre-School Booster (Diphtheria, Tetanus, Whooping Cough, Polio)
3 in 1 Teenage Booster (Diphtheria, Tetanus, Polio)
Meningitis (Meningococcal types A, C, W, Y)
Optional Vaccinations*
 Date(s) of Immunisation
Chickenpox
BCG (Tuberculosis)
Influenza
Hepatitis B
Travel Vaccinations
 Date(s) of Immunisation
Typhoid
Cholera
Yellow Fever
Meningitis (Meningococcal types A and C)
Hepatitis A
Hepatitis B
Japanese Encephalitis
Tick-borne Encephalitis
Rabies
Other

Medication and Treatment

Medication and Treatment
 Name of medication/treatmentReason for medication/treatmentDosage (if applicable)Frequency

Injuries, Accidents and Operations

Additional Information

I/We have provided full and complete information about my/our child in this 'Medical Information Form'.

I/We agree to inform the School in the event that my/our child's health or needs change.

I/We also agree to inform the School of any medication or treatment my/our child is receiving, as I understand that appropriately qualified School staff may administer medication or need to refer on.

Medical Consent

1. First Aid: I/We consent to appropriately trained and qualified members of the School staff administering first aid to my/our child where appropriate.

2. Medical treatment: I/We hereby give my/our consent for the School to act on my/our behalf as necessary for my child’s welfare if they require a medical examination, medical testing or minor medical treatment such as attendance at a local GP, Doctor or Optician.

3. Emergency treatment: I/We give my/our consent for the Head to act on our behalf to authorise emergency medical treatment as necessary for my child’s welfare in the event I/we cannot be contacted in time.

4. The administration of medicines: I/We hereby give consent for appropriately qualified members of the School staff to administer prescription medication as listed in the ‘Medication’ section of the ‘Medication and Treatment’ section of the ‘Medical Information Form’, or as subsequently notified to the School, and/or non-prescription medication such as Paracetamol, Ibuprofen, simple cough linctus, indigestion remedies and other over-the-counter remedies under protocols from the School Doctor for treating minor ailments.

*
 First SignatorySecond Signatory
Signature:
Title (e.g. Mr, Mrs, Ms):
Name in full (please include all names):
Relationship to child:
Date:
ISOTY 22
ISOTY 23
Artsmark Platinum
Talk Education
Good Schools Guide
Operation Encompass
Prevent
Charitable status. Warwick Independent Schools Foundation is a Registered Charity, number 1088057. It exists to provide quality education for children aged 3 to 18.

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