Medical Form

This form is to be completed by parents/guardians of pupils who have an existing medical condition or allergy.

Medical Condition and Administration of Medicines

* Indicates required field

Child's name *

First

Last

Child's Date of Birth *

Emergency Contact 1 *

First

Last

Contact number *

Emergency Contact 2 *

First

Last

Contact number *

Emergency Contact 3 *

First

Last

Contact number *

Child's Doctor *

First

Last

Contact number *

Please provide details of your child's medical condition/allergy *

What are the presenting symptoms for this medical condition/allergy? *

Might the child require the administration of medicine for this condition/allergy? *

Yes No

If yes, please provide details of the medicine here: *

Where will the medicine be stored? *

What dosage is required? *

Please record the steps to be taken in caring for the child e.g. how to administer the medicine *

Is the child to be responsible for taking the medicine him/herself? *

Yes No

Any additional information: *

Signed *

First

Last

Submit