Student Medical History Form Allergies/Dietary Needs

Student Medical History Form Allergies/Dietary Needs

All information is treated as confidential and is only available to school medical staff and to the relevant teaching staff and form tutors
Student Name

First NameLast Name
Year Group
My child has allergies and/or specific dietary needs
The school can cater for the following student diets:

1)Vegetarian
2)No pork/No beef
3)Lactose/Diary free
4)Gluten free
5)Egg free
6)Soya free
7) Low Fructose

Please note that the school does not provide or cater for nut free diets
Please provide any relevant information in the appropriate sections below
Allergies (including all allergies, drug, food, pollen, etc) Please include any symptoms the school may need to be aware of.
Does your child take any medication for the above?
If yes, please state the name, dosage and instructions
Serious illness in the past year (including broken bones) Please provide the details
Chronic medical condition (asthma, diabetes, seizure disorder, etc)
Does your child take any medication for the above?
If yes, please state the name, dosage and instructions
Please upload any supporting medical documentation if available

Browse Files

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Authorisation

I/We understand that whilst the school will make all reasonable efforts to contact me/us in the case of a medical emergency, this is not always possible. Therefore, I/we authorise the school to seek medical advice and treatment for our child if the school believes there to be an emergency and I/we hereby undertake to pay all costs incurred by the school. I hereby also give consent for the medical staff to administer the above mentioned medication (if applicable) as per my instructions.
Parent Signature
Date

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Student Medical History Form Allergies/Dietary Needs

Please provide any relevant information in the appropriate sections below

Authorisation