Medical Consent & Emergency Contact Form
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2MEDICAL CONSENT & EMERGENCY CONTACT FORM
Student
(First)
(Last)
Class:
Male
Female
Name:
Date of
Age:
Height:
Weight:
Religion (if any):
Class Teacher:
Birth:
Nationality:
ID/Passport Number:
Blood Type (if known):
Home address:
Town/City:
Postal Code:
EMERGENCY CONTACTS
(1) Name:
Relationship:
Day-time Telephone:
Mobile:
Home Telephone:
(2) Name:
Relationship:
Day-time Telephone:
Mobile:
Home Telephone:
SIBLING(S)
1)
Name:
Class:
(3) Name:
Class:
2)
Name:
Class:
(4) Name:
Class:
MEDICAL INSURANCE
Does your child have medical insurance?
YES/NO*
Medical Insurance Provider: ____________________________________
Policy Number: _________________________ Insurance Emergency Call Centre Number: _________________________________
*If your child has no insurance policy, please tick () the box and sign below:
I acknowledge that my child has no medical insurance policy and that I will be responsible for any fees incurred due to personal loss or
injury.
MEDICAL and DIETARY INFORMATION
Please indicate with a tick () if your child suffers any of the following:
Travel Sickness
Bed Wetting
Seizures of any type
Heart Condition
Recent breaks or sprains
Epilepsy
Sleepwalking
Asthma
Diabetes
Migraine Headaches
Fainting
Allergies
My child has been in contact with or has suffered from a contagious or infectious disease in the last four weeks.
Others (Please specify):
Please give further details of ANY boxes that you have ticked, or any other relevant information, including dietary considerations or recent
surgeries. Please write N/A if there is nothing to add.
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MEDICATIONS
My child does not require any medication in school OR
Please complete the table below if your child is on ANY medications (Prescription or non-prescription, including traditional):
Name of medication (in English)
Reason for Medication
Daily Timing and Dosage
All medications must be clearly marked in English with pupil’s name, name of medication, dosage amount and when medication is given.
Except for EPIPEN & INHALERS, pupils are not permitted to be in possession of any medication whilst on a school trip.
A member of School staff, prior to departure, will collect all medications. All medications will be kept in the first aid kit & administered by
staff.
NON-PRESCRIPTION MEDICATIONS
I give my permission for my child to receive oral, non-prescription medications if necessary (i.e. Paracetamol, Panadol)
YES
NO
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