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Summer school medical form We require this form to be completed so that the doctors have the necessary information for any illness that may occur. Please be assured that any information given will be treated as strictly confidential
Student information: Student family name:  

Student first name:  

Student date of birth:


Student gender:  

Emergency contact details: Contact family name:  

Contact First name:  

Contact main telephone number: Area code    

Contact secondary telephone number: Area code

Relationship to student:

Contacts level of English:

Contacts first language:

Student personal information:
Do you have any dietary requirements?

Are you allergic to anything?

Do you have, or have you had, any of the following conditions:
Asthma
Eczema
Hay fever
Epilepsy
Heart trouble
Diabetes
Kidney or urinary disease
Bone or joint trouble
Dental problems
Hearing/sight problems
Mental health conditions

Is there any other feature of your physical or psychological health of which you think the College Nurse should be aware?

Do you take regular medication?
Medical attention and first aid treatment: I give authority to the Summer Course Director of Concord College or his/her representative to give consent for first aid, medical attention and urgent medical treatment to be administered to my child including surgery, blood transfusions and the use of anaesthetic.
Permission to authorise medical treatment:  

The college will refer to your child’s medical history and any medical information you submitted to us as part of the enrolment procedure. If your child’s medical conditions or your contact details change, please inform the college so we can update our records accordingly.