Medical Form

Easter Playscheme 2024 Medical Form

Please fill in the Medical Form for your child to enable them to attend the 2024 Easter Play Scheme

RM_Stats

Name

Email^*

Doctors Name

Doctor's Address

Address Line 1

Address Line 2

City

County

Country

Postcode

Doctor's Telephone Number

Are There Any Medical Issues We Need To Be Aware Of?

Medication Useage (Including Dosage and when last taken)

Is your Child up to date with Immunisations?

Date of Last Tetanus Booster

I allow my child to have plasters administered if required

(Please Sign) Consent for Medical Advice and Treatment to be sought if Necessary

Please Indicate If Any Specialist Consent is required (i.e Social Worker etc)

Does your child have any special needs (Please advise details)

Consent Signature (Please Click on Box for Details)

Please read and sign below to say you agree to the following: - I, or an authorised person over 16 will collect my child at the end of each day (all children) ** (If this presents a problem for anyone – please speak to the Playscheme Co-ordinator ** I allow staff to keep relevant confidential records ** I allow for photos to be taken for use within playscheme and for occasional publicity ** I allow my child to participate in playscheme activities including outdoor activities ** I will provide a sunhat and ensure sun cream is applied before arriving at playscheme ** Signed (by the person with the legal responsibility of the child)

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