WELLS MUSIC SUMMER SCHOOL MEDICAL FORM

Medical History

Child's name

Your name

Your email

Does your child suffer from (tick as appropriate)

AsthmaEczemaEpilepsyDiabetes

If yes, please give brief details

Please give details if your child has any allergies to food, medication or stings.

Please give details if your child is on any medication.

Please give details if your child has a special diet.

Please give details if your child has travelled abroad recently (other than the UK).

If your child wears glasses/contact lenses, please state when he/she was last tested.

Please give details if your child has ever been treated in hospital.

Please give details if your child has had any operations or severe illnesses not mentioned above.

Please provide details of any special needs or disabilities your child may have.

Childhood Diseases

Please give the date when your child has had these illnesses (if applicable):

Chicken pox
Mumps
Diphtheria
Measles
Rheumatism
Rubella
Scarlet Fever
Whooping Cough

Epi-Pens

If your son/daughter carries an epi-pen, please provide him/her with two spare epi-pens in addition to the one your child carries. An epi-pen will be given to the member of staff supervising your child to be used in case of emergency.

Please click here to read our Privacy Notice.

Complete the Booking Process

Please note that we will email you confirmation of your medical information with the links below.

To complete the booking process, if you haven't done so already, please follow this link to complete your registration form. You will also need to follow this link in order to make payment. Please note to make the payment you will need to set up an account the first time you book a course.