MEDICAL FORM 2023/2024

MEDICAL FORM 2023/2024

STORTFORD KIDSOUT requires details of relevant medical history for each of your children. It is your responsibility to keep us up to date with any changes or new developments
CHILDS NAME*

First NameLast Name
DOB*
DOCTOR'S NAME AND ADDRESS*
DOCTOR'S TELEPHONE NUMBER*

Area CodePhone Number

QUESTIONS

If you answer 'Yes' to any of the following questions, please provide us with more information
Does your child have a known medical condition?*

YesNo
Please provide us with more information
Medical Condition
Does your child have any known allergies?*

YesNoOccasionally
Please use this space to tell us about your child's allergies
Allergies

Does your child have any special dietary requirements?*

Milk, lactose intolerantWheat free / Gluten freeNo eggsNutsNo special requirements
Is your child currently on medication?*

YesNo
Please list the medication below
Medication
If you require us to give medication, you will need to complete a short term or long term Medicine Permission Form. The club leader will provide you with this.

EMERGENCY MEDICAL TREATMENT PERMISSION

In the event that my child requires immediate medical treatment before I can get to the hospital and/or if I cannot be contacted, I hereby authorise the senior member of staff present to consent on my behalf to emergency medical treatment only, to ensure the health and wellbeing of my child.
Parent / Carer Emergency Contact Telephone Numbers*
Contact in Emergency
ANY OTHER INFORMATION
Information
By providing your name below, you are agreeing to share relevant medical information *

First NameLast Name
Email
example@example.com
CONSENT*

I confirm I am the child's motherI confirm I am the child's fatherI confirm I am the child's legal guardian
Should be Empty: