MEDICAL FORM 2024/2025

MEDICAL FORM 2024/2025

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 PRESCRIBED medication, you will need to complete a short term or long term Medicine Permission Form. The club leader will provide you with this. We do not administer NON-PRESCRIBED medications

EMERGENCY MEDICAL TREATMENT PERMISSION

This is a LAST RESORT consent. We will continue our attempts to establish contact with you or any of your listed contacts before acting on your behalf.

In the event that my child requires immediate medical treatment before I can get to the hospital and/or if I cannot be contacted or my emergency contact, I hereby authorise the senior member of staff present to consent on my behalf to emergency medical treatment requested by a medical/first responder specialist, to ensure the health and wellbeing of my child.
Parent / Carer Emergency Contact Telephone Numbers*
Contact in Emergency
ANY OTHER INFORMATION - You have the right as a parent to inform us of your wishes. Please include here any specific emergency treatments you do not consent to e.g. blood transfusions, x-rays. Please provide your reason/s.
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: