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Myddelton College New Starter Form
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Myddelton College New Starter Form
Please complete the below form by July 31st.
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Step
1
of 6
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
--- Select country ---
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia (Plurinational State of)
Bonaire, Saint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo (Democratic Republic of the)
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Kingdom of)
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran (Islamic Republic of)
Iraq
Ireland (Republic of)
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea (Democratic People's Republic of)
Korea (Republic of)
Kosovo
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia (Federated States of)
Moldova (Republic of)
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia (Republic of)
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine (State of)
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin (French part)
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten (Dutch part)
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syrian Arab Republic
Taiwan, Republic of China
Tajikistan
Tanzania (United Republic of)
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
Uganda
Ukraine
United Arab Emirates
United Kingdom of Great Britain and Northern Ireland
United States Minor Outlying Islands
United States of America
Uruguay
Uzbekistan
Vanuatu
Vatican City State
Venezuela (Bolivarian Republic of)
Vietnam
Virgin Islands (British)
Virgin Islands (U.S.)
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
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
--- Select country ---
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia (Plurinational State of)
Bonaire, Saint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo (Democratic Republic of the)
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Kingdom of)
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran (Islamic Republic of)
Iraq
Ireland (Republic of)
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea (Democratic People's Republic of)
Korea (Republic of)
Kosovo
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia (Federated States of)
Moldova (Republic of)
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia (Republic of)
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine (State of)
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin (French part)
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten (Dutch part)
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syrian Arab Republic
Taiwan, Republic of China
Tajikistan
Tanzania (United Republic of)
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
Uganda
Ukraine
United Arab Emirates
United Kingdom of Great Britain and Northern Ireland
United States Minor Outlying Islands
United States of America
Uruguay
Uzbekistan
Vanuatu
Vatican City State
Venezuela (Bolivarian Republic of)
Vietnam
Virgin Islands (British)
Virgin Islands (U.S.)
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
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
Next
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
--- Select country ---
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia (Plurinational State of)
Bonaire, Saint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo (Democratic Republic of the)
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Kingdom of)
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran (Islamic Republic of)
Iraq
Ireland (Republic of)
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea (Democratic People's Republic of)
Korea (Republic of)
Kosovo
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia (Federated States of)
Moldova (Republic of)
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia (Republic of)
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine (State of)
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin (French part)
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten (Dutch part)
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syrian Arab Republic
Taiwan, Republic of China
Tajikistan
Tanzania (United Republic of)
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
Uganda
Ukraine
United Arab Emirates
United Kingdom of Great Britain and Northern Ireland
United States Minor Outlying Islands
United States of America
Uruguay
Uzbekistan
Vanuatu
Vatican City State
Venezuela (Bolivarian Republic of)
Vietnam
Virgin Islands (British)
Virgin Islands (U.S.)
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
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
--- Select country ---
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia (Plurinational State of)
Bonaire, Saint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo (Democratic Republic of the)
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Kingdom of)
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran (Islamic Republic of)
Iraq
Ireland (Republic of)
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea (Democratic People's Republic of)
Korea (Republic of)
Kosovo
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia (Federated States of)
Moldova (Republic of)
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia (Republic of)
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine (State of)
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin (French part)
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten (Dutch part)
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syrian Arab Republic
Taiwan, Republic of China
Tajikistan
Tanzania (United Republic of)
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
Uganda
Ukraine
United Arab Emirates
United Kingdom of Great Britain and Northern Ireland
United States Minor Outlying Islands
United States of America
Uruguay
Uzbekistan
Vanuatu
Vatican City State
Venezuela (Bolivarian Republic of)
Vietnam
Virgin Islands (British)
Virgin Islands (U.S.)
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Next
Immunisations and Vaccinations
Please provide dates if possible.
Diptheria (Please provide dates of vaccination and any boosters)
Tetanus (Please provide dates of vaccination and any boosters)
Pertussis (Whooping Cough) (Please provide dates of vaccination and any boosters)
Polio (Please provide dates of vaccination and any boosters)
Hib (Please provide dates of vaccination and any boosters)
MMR (Please provide dates of vaccination and any boosters)
BCG (against TB) (Please provide dates of vaccination and any boosters)
Allergies and Sensitivities
Please list any allergies that your child has.
*
Include details of the allergen nature (trigger to allergy), extent and severity of the reaction, signs and symptoms and the treatment of the allergy. If no allergies, write ‘None’.
Next
Dietry Requirements
Is your child able to eat a normal school diet?
*
Yes
No
If 'no', are they:
Vegetarian
Vegan
Special Diret
Please provide any further information and / or reasons for dietry requirements.
Exercise
Is your child able to take part in physical exercise (games, PE, swimming, etc.)?
*
Yes
No
Please specify any restrictions:
Hearing and Sight
Has your child had any eyesight or hearing tests?
*
Yes
No
Were there any problems?
*
Yes
No
If yes, please specify:
Family Background
Are both parents alive and well?
*
Yes
No
Are parents seperated?
*
Yes
No
Are there any illnesses that run in the family?
*
Yes
No
e.g. Epilepsy, Asthma etc.
If yes, please specify:
Next
Overseas Travel & Residence Abroad
Has your child lived in or travelled through countries where special immunisations or health precautions are required?
*
Yes
No
e.g. Malaria, Yellow Fever, Typhoid, Cholera or Hepatitis
If yes, please specify which countries:
Medication
Is your child taking drugs of any description, either prescribed by a doctor or bought from a chemist?
*
Yes
No
including pills, medicines, injections, creams, inhalers and vitamins.
If yes, please specify:
Please include: Name of Drug, Dose, Frequency Taken, Route Taken, Home Remedy or Prescriptionm and Condition
Chest X-Ray
Has your child had a recent chest x-ray?
*
Yes
No
If yes, please specify:
Please include: the date of X-Ray and results.
Have they ever been in contact with anyone with active tuberculosis?
*
Yes
No
If yes, please specify:
Please include: the date.
Past and Present
Has your child had, or have, any of the following?
Congenital abnormalities
Eczema
Rheumatic fever
Psoriasis
Heart murmurs
Urticaria
Acne
Cerebral palsy
Asthma
Hay fever
Faints or blackouts
Diabetes
Epilepsy
Fits or convulsions
Hepatitis
Jaundice
Gynaecological problems
Bedwetting
Serious accidents
Blood transfusions
Eye problems
Discharging ears
Tuberculosis
Malaria
Other tropical illnesses
Anxiety
Depression
Polio
Rheumatism
Poor hearing
Poor eyesight
Operations
Anaemia
Chicken Pox
Mumps
Measles
Eating disorders
Whooping Cough
Rubella
Impetigo
Shingles
Scabies
Cystitis
Orthopaedic problems
Any other problems
Please provide full details of any illnesses to which you have checked above.
Accidents - Please list giving nature, dates and subsequent effects.
Disability - Please provide full details of any disabilities that your child may have. Include the nature, extent and severity of the disability, and care and treatment of your child in relation to the disability.
Specific Learning Difficulties - Please provide full details of any specific learning difficulties or special needs that your child may have. Include details of the nature, extent and severity of the need and its management, care and treatment.
Next
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).
*
I confirm that I have read the above disclosure and I am happy to proceed.
I confirm that I have read the above disclosure and I would like more information.
*Available upon request from the School Office
Consent of self administration of medication assessment
*
I confirm that I have read the disclosure and I am happy to proceed.
I confirm that I have read the disclosure and I would like more information.
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.
*
I confirm that I have read the below disclosure and I am happy to proceed.
I confirm that I have read the below disclosure and I would like more information.
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:
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