Myddelton College New Starter Form

Medical Information (Confidential)

Student's Name *

Student's Date of Birth *

Format: DD/MM/YYYY

Student's Place of Birth *

Student's Gender *

Female
Male

Student's NHS Number *

Student's Home Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Student's Phone Number *

GP Information

GP Name *

GP Phone Number *

GP Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Please note: all boarders will be registered with: Beech House Surgery, 69 Vale Street, Denbigh, Denbighshire, LL16 3AY 01745 812 863

Student Status *

Day Student
Weekly Boarding Student
Full Boarding Student

Emergency Contact Details

Primary Contact Name *

Primary Contact Relationship to Student *

Primary Contact Phone Number *

Primary Contact Alternative Phone Number

Primary Contact Home Address (if different from students)

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Secondary Contact Name *

Secondary Contact Relationship to Student *

Secondary Contact Phone Number *

Secondary Contact Alternative Phone Number

Primary Contact Home Address (if different from students) (copy)

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Permissions

I give my consent for the named child applicant to be given medication in accordance with the Myddelton College Administration of Medication and First Aid Policy’ * And hereby give permission for my child to have any relevant first aid treatment from Myddelton College’s first aider(s). *

*Available upon request from the School Office

Consent of self administration of medication assessment *

I agree to the school’s first aiders conducting a self-administration of medical assessment with the names child applicant andI understand that this assessment will only assess my son/daughter’s practical competence to administer his/her own medication. The assessment will not assess his/her emotional/psychological readiness to administer her own medication.

Please add any further information you think may be relevant in the box below.

Participation in Outdoor Adventure Education, School Trips and other activities. *

a) I am happy for my child / the applicant, to take part in OAE, school trips and other activities that take place off school premises; and b) To be given first aid or urgent medical treatment during any school trip or activity. Please note the following important information before signing this form: The trips and activities covered by this consent include: • All visits (including residential trips) which take place during the holidays or weekend • OAE/adventure activities at any time • On/off-site sporting fixtures outside the school day • The school will send you information about each trip or activity before it takes place. • You can, if you wish, tell the school that you do not want your child to take part in any particular school tripor activity • This form will be valid for the duration of your son/daughter’s time at Myddelton College. If there are anymedical changes, please resubmit another form. Written parental consent will not be requested from you for the majority of off-site activities offered by the school - for example, year-group visits to local amenities - as such activities are part of the school’s curriculum and usually take place during the normal school day. For any cost above £30 for an activity/trip a separate letter of request will be made to parents.

Details of any medical condition that my child suffers from and any medication my child should take during off-site visits: