This form is to be completed by parents or guardians of pupils soon to start at Woodhouse Grove School. To complete the form you will need to have been sent a verification code from the school by email first.

Verification code: *
Your name: *
Child's name: *
Child's D.O.B *
Your relationship to child: *

Doctors

GP Practice Name:
GP Practice Address:

Medical Conditions (not allergies or food intolerances, see below)

Does your child have a medical condition which the School needs to be aware of? *

Please include details of any neurodiversity that you wish the School to be aware of in this section.

Condition 1 - Name
Condition 1 - Trigger/Symptoms
Condition 1 - Treatment. Please detail any regularly used medication here.
Condition 2 - Name
Condition 2 - Trigger/Symptoms
Condition 2 - Treatment. Please detail any regularly used medication here.
Condition 3 - Name
Condition 3 - Trigger/Symptoms
Condition 3 - Treatment. Please detail any regularly used medication here.
Does your child have any more medical conditions?
Condition 4 - Name
Condition 4 - Trigger/Symptom
Condition 4 - Treatment. Please detail any regularly used medication here.
Condition 5 - Name
Condition 5 - Trigger/Symptoms
Condition 5 - Treatment. Please detail any regularly used medication here.
Condition 6 - Name
Condition 6 - Trigger/Symptoms
Condition 6 - Treatment. Please detail any regularly used medication here.
If your child has more than 6 allergies please provide details of the allergy, trigger/symptoms and treatment:

Allergies (including food intolerances)

Does your child have an allergy which the School needs to be aware of? *
If your child has any allergy action plans please upload them here:

Please provide details of allergies that your child suffers from that the School needs to be aware of:

Allergy 1 - Name
Allergy 1 - Trigger/Symptoms
Allergy 1 - Treatment. Please detail any regularly used medication here.
Allergy 2 - Name
Allergy 2 - Trigger/Symptoms
Allergy 2 - Treatment. Please detail any regularly used medication here.
Allergy 3 - Name
Allergy 3 - Trigger/Symptoms
Allergy 3 - Treatment. Please detail any regularly used medication here.
Does your child have any more allergies?
Allergy 4 - Name
Allergy 4 - Trigger/Symptoms
Allergy 4 - Treatment. Please detail any regularly used medication here.
Allergy 5 - Name
Allergy 5 - Trigger/Symptoms
Allergy 5 - Treatment. Please detail any regularly used medication here.
Allergy 6 - Name
Allergy 6 - Trigger/Symptoms
Allergy 6 - Treatment. Please detail any regularly used medication here.
If your child has more than 6 allergies please provide details of the allergy, trigger/symptoms and treatment:

Emotional Issues

Has your child received, or is receiving support for emotional issues that you wish the School to be aware of? *
Please provide details of the emotional issue which you wish the School to be aware of:

Significant Medical History

Please provide details of any significant medical history, such as surgeries or major injuries, that you wish the School to be aware of:


Diet

Does your child require a vegetarian diet? *
Does your child require a vegan diet? *
Please list any religious dietary restrictions

Vaccination History 

This section is to be completed for Boarding Pupils only.

If 'Yes' then please complete the extra questions below listing the date(s) of the occasions on which your child has received the vaccination. e.g. 01/02/20, 02/03/21, 04/05/22

Is your child a boarder? *


Covid-19 Vaccination dates:
DTP or DTaP (Diphtheria/ Tetanus/Pertusis) dates:
Poliomyelitis (Polio IPV) dates:
MMR (Measles, Mumps, Rubella) dates:
TB (BCG) (Tuberculosis) dates:
Meningitis B dates:
Meningitis C dates:
HIB (Haemophilus Influenza B) dates:
Hepatitis A dates:
Typhoid dates:
Hepatitis B dates:
Varicella (Chicken Pox) dates:
Shingles dates:
Flu vaccine dates:
HPV dates:
Men ACWY (Meningococcal disease which is meningitis and septicaemia strains A, B, C and Y) dates:
Men ACWY (Meningococcal disease which is meningitis and septicaemia strains A, B, C and Y) Booster dates:
Pneumococcal (PCV) dates:
Rotavirus dates:
dT/IPV (Teenage Booster) dates:

Consent

My child is Asthmatic and I give consent to use the school emergency inhaler in the event that their own inhaler is not available? *

If 'Yes' to the question above please ensure that you have provided specifics in the Medical Conditions section above. Answering 'Yes' to this question will reveal additional questions to provide specifics. 

I give consent for over the counter medication to be given by medicine administration competent staff if required: *
Please list any over the counter medication not allowed:
I give consent for first aid to be administered by a qualified member of staff in case of emergency *
If the School is unable to contact a next of kin I consent for the School to provide the hospital with emergency operation consent if recommended by a senior medical officer: *

Please ensure that any changes to your child's medical information is communicated to the medical centre as soon as possible.  

Details on how Woodhouse Grove School will use the information you provide can be found at www.woodhousegrove.co.uk/yourprivacy

Thank you for taking the time to complete this form, 

The Woodhouse Grove medical centre team:

medicalcentre@woodhousegrove.co.uk 

01132502477

I am signing this form electronically as somebody with parental responsibility for the child named above. The information within the form is accurate to the best of my knowledge and this electronic signature is the legal equivalent of my manual signature. *

Please do not use the 'Send me a copy of this form' form functionality below. This functionality will pick the last entered email address from the form above which may be different from your email address.

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