Medical Information and Consent Form

The Gardens Childcare Ltd. Company No. 07707020. Ofsted No.455318

Please 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 he/she is a pupil at the Nursery.

All information received on this form will be treated in confidence.

For more information about how the Nursery may use your and your child's information contained in this form, please see our privacy notice which is enclosed with the email of offer and published on the Nursery website: https://www.gardenschildcare.co.uk/privacy-policy
Child's details*

Child's Name

DOB


Child's Name
DOB

Child's doctors details*


Doctors Surgery
Doctors Name
Surgery Tel Number

A letter from your doctor is required if your child suffers from any chronic allergy, medical conditions or food intolerances.

Browse Files

Cancelof

Has your child had any of the following allergies?*

	Yes/No	Details	How does your child react?
Hayfever
Medicine
Animals
Foods
Other

Does your child have any birthmarks?
Please give details of all FOODS your child is unable to eat due to health, dietary or religious reasons & please explain how your child reacts to them?
Please give details of all known MEDICAL and/or MENTAL HEALTH CONDITIONS including any previous conditions

Does your child require any medication or treatment throughout the day (inlude Epi-Pen or other Auto Injector)?

	Name of Medication	Reason	Dosage	Frequency
1.
2.
3.

We keep an emergency supply of Calpol at the nursery. If you are happy to allow us to administer this as necessary (e.g if your child has a high temperature and we are unable to contact you or you are delayed in collecting them) please tick this box.*

Yes please administer Calpol to my childNo please do not administer Calpol to my child
We keep an emergency supply of teething granules at Nursery. NELSONS Theetha Teething Granules is a homeopathic medicinal product used within the homeopathic tradition for the symptomatic relief of teething pain and the symptoms associated with teething which are sore and tender gums, flushed cheeks and dribbling. If you are happy to allow us to administer this as necessary (e.g. if your child is suffering from teething and we are unable to contact you or you are delayed in collecting them) please tick this box*

Yes please administer Nelsons Teething Granules to my childNo please do not administer Nelsons Teething Granules to my child

Has your child had any of the following infectious diseases?*

		Date of Infection
Chicken Pox
Measles
German Measles
Whooping Cough
Mumps

If you have answered Yes to any of the above, please provide details below.
Has your child been in contact with anyone with an infectious or contagious disease? If yes please provide details below.

Immunisations - Please provide date(s) of immunisation of your child where indicated or, if immunisation has not been carried out, please indicate accordingly;*

	Date of Immuisation
6 in 1 Vaccine (Diphtheria,Tetanus,Whooping Cough, Polio, Hepitisus B, HIB)
HIB / Men C
MMR (mandatory for entry to The Gardens)
Children's Flu Vaccine
Pneumococcal (PCV)
MenB
Rotavirus
Chicken Pox (optional vaccination)

MMR vaccinations

Please note that it is a requirement that all children have received the MMR vaccination prior to entry to The Gardens Nursery School.

I/We understand that my/our child is required to have the MMR vaccination from the age of 1 year old if I/we wish for him/her to attend The Gardens Nursery School.
I/We confirm that my/our child has had the MMR vaccinationI/We confirm that my/our child will be having the MMR vaccination at 12 months old.
Other declarations

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

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

I/We also agree to inform the Nursery of any medication or treatment my child is receiving as I understand that appropriately qualified Nursery staff may administer medication or need to refer on to Medical, Dental and Optical specialists as required.

I/We understand that the Nursery has a 48 hour sickness policy and a 24 hour temperature policy. I/We agree that I/we will not bring my/our child to the Nursery until:
- 48 hours has passed since the last symptom if my/our child is suffering with sickness and/or diarrhoea; and
- 24 hours has passed from his/her last raised temperature if my/our child is suffering with a raised temperature.
Name of first signatory (as appears on the confidential information & registration form)*

First NameLast Name
Signature of first signatory*

Clear
Date*

DayMonthYear
Date
Name of first signatory (as appears on the registration form)*

First NameLast Name
Name of second signatory (as appears on the confidential information & registration form)*

First NameLast Name
Signature of second signatory*

Clear
Date

DayMonthYear
Date

Medical Consent
1. First Aid: I/We consent to appropriately trained and qualified members of the Nursery staff to administer first aid to my/our child where appropriate.
2. Medical treatment: I/We hereby give my consent for the Nursery to act on my/our behalf as necessary for my child's welfare if he/she requires a medical examination, medical testing or minor medical treatment such as attendance at a local GP, Doctor or Optician.
3. Emergency Medical Treatment: I/We give my/our consent for the [Nursery Manager/Principal] 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 give my/our consent for appropriately qualified members of the Nursery 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 Nursery. I/We understand that the Nursery will seek our prior consent to the administration of non-prescription medication, with the exception of 'Calpol'. I/We understand that the Nursery will only administer 'Calpol' if my child has a temperature and I/We consent to the Nursery administering 'Calpol' in these circumstances.
5. Suncream: The Nursery requires all children to be protected by sunscreen throughout the summer months. The Nursery uses an organic sun cream from TheGreen People that has been specially recommended for babies and children
I/We hereby give my/our consent for the Nursery to apply the Nursery's chosen brand sun cream to my/our child.*I/We confirm that I/we will be providing my/our own sun cream and I we hereby give my/our consent for the Nursery to apply my/our chosen brand sun cream to my/ our child.*
If there is any medication or remedies you would prefer your child not to receive please indicate these in the box below.
Relationship to child
Type a question
Signature of first signatory*

Clear
Date*

DayMonthYear
Date
Name of second signatory (as appears on the registration form)*

First NameLast Name
Relationship to child
Signature of second signatory*

Clear
Date*

DayMonthYear
Date
Should be Empty:

Medical Consent