Medical Form (CONFIDENTIAL)

Please complete all sections of this form clearly. All boarders, including weekly boarders, will be registered at Wells Health Centre. If there are changes in any of the details during your child’s stay please inform us. The information provided does not affect the school’s application process. It is treated in strict confidence and shared with appropriate school staff on a need to know basis only, and in accordance with the school’s Data Protection Policy and Privacy Notice, in order to safeguard the pupils’ best interests and safety.

General Information - Step 1 of 4

Forename(s) *

Likes to be known as (preferred name)

Surname *

Previous surname

Proposed start date *

Day or Boarder *

Day Pupil
Boarder (including Weekly Boarders)

Date of Birth *

Year Group *

Gender *

Male
Female

Please let us know if there is any information relating to the pupil's gender that we should be aware of

Town and country of birth *

Your most recent UK address (if applicable)

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

If you're from abroad, the first UK address where registered with a GP (if applicable)

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Who has legal contact and daily parental responsibility?

NHS Number

Private Medical Insurance

Current or most recent GP in UK (if applicable)

Please include contact details

Address of GP (if applicable)

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Save and Resume Later

Does your child have any of the following medical conditions (tick all that apply)

Allergies
Asthma
Diabetes
Eczema
Epilepsy

Letter from the GP (if available)

Click or drag a file to this area to upload.

If you still need to acquire a letter, please email it once received to [email protected]

Please include what your child is allergic to and any details of any treatment required.

Does this cause an anaphylactic reaction?

Please provide a copy of your allergy action plan if available

Click or drag a file to this area to upload.

Has the child been prescribed an adrenaline auto-injector (aka EpiPen)

The Human Medicines Regulations 2017 will allow schools to administer their “spare” adrenaline auto-injector (AAI), obtained, without prescription, for use in emergencies, if available, but only to a pupil at risk of anaphylaxis, where both medical authorisation and written parental consent for use of the spare AAI has been provided (Department of Health).

I give my consent for the School to administer their “spare” adrenaline auto-injector (AAI), obtained, without prescription, for use in emergencies.

EpiPens -Please provide the School with at least one spare pen in addition to the one your child carries. In case of emergency all school staff are aware that they can access an EpiPen in the Catering Department and St. Andrew’s Lodge.

Insulin - If your child is prescribed insulin please provide St. Andrew’s Lodge with a spare giving device and insulin in case of breakages, loss or emergencies.

The Human Medicines Regulations 2014 allows schools to provide an emergency Ventolin Inhaler to be used by children who have either been diagnosed with asthma and prescribed an inhaler, or who have been prescribed an inhaler as a reliever medication.

I give my consent for the School to use an emergency Ventolin Inhaler if the pupil's prescribed inhaler is not available.

Asthma Reliever Inhaler – This should be carried at all times especially for sport and to have a spare in case of loss. You may wish to provide St. Andrew’s Lodge with a spare in case of emergencies.

Regular Medication (e.g. prescription/over the counter/herbal) Day Pupils - medication is stored safely and administered by a trained member of staff, the parent will be notified where possible. Boarding Pupils – medication is stored in house and administered by house staff unless they have been assessed as safe to administer and store their own medication

Medicines prescribed outside the UK – some medicines are not licensed in the UK. Please let us know in advance if your child takes regular prescribed medication. Please do not send any over the counter or Chinese medicines as they are also not licensed to be used in the UK.

Are there any over the counter medicines you do not wish your child to receive?

In order for the School to provide care and support for your child, please provide information regarding any mental health concerns; including details of any treatment your child is receiving, or has received in the past (ie. counselling, medication, psychotherapy, CAMHS).

Does your child require a special diet? (e.g. vegetarian/vegan/pescatarian/nut free/dairy free/gluten free/wheat free/ reducing or fortified diet) *

Please provide details of the special diet requirements and the reason(s) for the special diet (e.g. preference/medical condition/allergy/intolerance) *

Religious/spiritual beliefs

Immediate Family Medical History (e.g. asthma, diabetes, eczema, epilepsy, coronary heart disease, hypertension, psychiatric illness)

Sight (glasses/contact lenses/date of last sight test, history of headaches)

Dental (previous/current notable problems/treatment) Rugby/Hockey – gum shields must be worn at all times in play.

Hearing (aid required/ear infections/excess wax buildup) Specialist musicians ear plugs are recommended for those who are exposed to loud sounds to prevent hearing loss or tinnitus.

Mobility (walking aid/wheelchair/scoliosis)

Do you have any concerns about your child’s growth?

In order to help us care for your child is there any history of bereavement, family break up, eating disorders or self harm and if so have they had any assessment, support or treatment?

Do you have any concerns about your child's physical or mental health, which you would like shared with the School Doctor?

Please note that all boarders will be registered at our local GP surgery, Wells Health Centre and registered with Dr John Machling.

Save and Resume Later

All pupils will be offered those vaccinations outlined by the routine UK immunisation schedule. Written consent will be asked for before any vaccination is administered, unless they are 16 years or over when they can consent for themselves. Boarders' immunisation records are shared with Wells Health Centre.

Before entering the UK from some overseas countries the border agency will require documentation on arrival ruling out Tuberculosis. For further information please click here.

Immunisations (Boarders only)

Please tick whether your child has received the vaccinations for the following diseases and then enter the dates received if applicable.

Diphtheria, Tetanus, pertussis, (whooping cough) polio, Haemophilius influenzae type b (Hib) and hepatitis B (Vaccination name: DTaP/IPV/Hib/HepB)

Did the pupil receive the DTaP/IPV/Hib/HepB vaccination? *