Medical Conditions in School Staff Awareness Form
Child’s Name____________________________ Date of Birth____________________________ Medical Condition________________________ ________________________________________ ________________________________________ Class/Year_______________________________ Contact Information Family Contact 1 Name__________________________________ Phone No: Home________________________ Work________________________ Mobile_______________________ Relationship____________________________ Clinic/Hospital Contact Name_________________________________ Phone No:_____________________________ |
Attach photo in school uniform here
Family Contact 2 Name__________________________________ Phone No: Home________________________ Work________________________ Mobile_______________________ Relationship____________________________ GP Name_________________________________ 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______________________________________________