Medical Conditions in School staff awareness

 

Medical Conditions in School Staff Awareness Form

Child’s Name ____________________________               Attach photo in school uniform here
 
     Date of Birth _____________________________
 
     Medical Condition_________________________
 
     ________________________________________
 
     ________________________________________
 
     Class/Year_______________________________
 
 
 
Contact Information                                                                                                     
 

Family Contact 1                                                Family Contact 2

Name_______________________________          Name____________________________
 
Phone No:        Home___________________         Phone No:        Home________________
 
                        Work___________________                               Work________________
 
                        Mobile__________________                               Mobile_______________
 
Relationship      ________________________       Relationship________________________
 
Clinic/Hospital Contact                                          GP
 
Name_____________________________      Name____________________________
 
Phone No:_________________________      Phone No:________________________
 
Please describe the condition and give details of the pupils symptoms:
 
 
 
 
 

Please describe any action that should be taken in case of emergency:

 

 
 

 

Parent’s signature_____________________________________________________