Show/Hide Mobile Menu

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______________________________________________

Website by ib3

Sitemap