Medical Information Record Form

NEW STUDENT  

Medical Centre

Lavington Park

Petworth, GU28 0NB


Telephone: 01798 867831

Email: medicalcentre@seaford.org 

Please ensure you check you have all the documents and information required before you submit the form.  

Please also do not leave any GAPS in the phone number's or the form may not submit.  Thank you

My Child requires support for: *

Contact Details

Surname of Child *
First Name: *
Preferred Name: *
Gender *
Date of Birth: *
Age: *
My Child is attending as a: *
Year Group: *
Main Home Address: *
Postcode: *
Home Phone Number: *
Name of Parent/guardian (1) *
Contact Number: Day/Evening *


Mobile: *
Relationship to Child: *
Name of Parent/guardian (2)
Contact Numbers: Day/Evening
Mobile:
Relationship to Child:

Emergency Contact:

Name: *
Contact Numbers: Day/Evening *
Mobile: *
Relationship to Child: *
Name of Current GP: *
Surgery Address: *
Postcode: *
Surgery Contact Number: *
Your Child's NHS No:

Medical History

Does your Child suffer from any of the following?

Emotional Wellbeing

Does you child have a need for Pastoral support as listed
Please use this space to add any additional information:

Conditions

Has your child suffered from any of the following conditions?
Are there any additional health concerns you wish to disclose? *
Please use this space to add any additional information

Immunisation History

Please provide us with a copy of your childs full immunisation schedule which you can request from your GP.
Add additional documents:

Please provide us with a copy of your child’s full immunisation schedule which you can request from your GP. Please enter dates in boxes below for Pre-school vaccinations *

8 weeks to 3 years old - DTaP/IPV/Hib/HepB, Men B
*
Pre-school (3-4 years old) DTaP/IPV *
12-13 Years old (school year 8) HPV Papillomavirus
14 years old (school year 9) TD/IPV (Check MMR status)
14 years old (school year 9) Men ACWY
Other Immunisation BCG

Other immunisation: Hepatitis A
Other immunisation: Hepatitis B
Other immunisation: Typhoid
Other immunisation: Yellow fever
Are there any reasons why your child cannot take part in normal school activities? *

Full boarding pupils will need to be registered with the local GP Surgery in Petworth whilst attending the school.  You will need to complete the Petworth Patient Registration form on firefly for your child before they start school.

Please confirm if they will be registered at the either Petworth Surgery, or their own GP or N/A

*

CONSENT FORM

Please read the following and give your consent or otherwise:

First Aid and Emergency Treatment

I give consent for my child to receive first aid whilst at Seaford college, or on an activity away from the school premises when required *
I give consent for my child to receive non-prescription medication, for example Paracetamol for a headache. I will inform the matrons, house parents and medical centre if my child should not be given any medication or homely remedies provided for simple ailments. *
I understand the Nurses and/ or designated safeguarding leads have a discretion to disclose to the headmaster and/or other members of staff in the strictest confidence any information which they may obtain concerning your child which they consider is in the best interests of the child, the school or any of the pupils. *
I agree to a member of staff giving permission for my child to receive appropriate medical treatment in case of an emergency *
I understand the school will, in the first instance seek parental permission for any urgent operation, general anesthetic etc., wherever possible, but will reserve the right to sign a consent form in an emergency when it is not possible to consult the parents where an immediate decision must be taken in the interest’s and safety of the child. *
If withholding consents for any of the previous points, please give details here:

Prescribed Medications

If your child is on prescribed medication, it is essential the medical centre is informed in writing at the start of term.

Any medication taken on the school premises must be monitored by the school nurse.

All prescribed medications need to be presented to the medical centre labelled with the childs name, in the original packet, with instructions, details of dosage and expiry dates.

It is the parent/guardian's responsibility to provide repeat prescriptions in a timely manner for their children.

You must inform the medical centre in writing if a pupil develops any known medical condition, suspected health problem or any allergy that may have an impact on their wellbeing whilst at Seaford College.

Please contact the nursing staff at the Medical Centre at any time to discuss any concerns regarding your childs health and wellbeing.
*
Add Prescription or letter for Child's medication. We need evidence of dose to be administered.
Additional Letters/reports on treatment or prescriptions from your Child's Consultant/CAHMS/Specialist/GP required to care for your Child in school.


Please list any medication your child is currently prescribed

Declaration

I confirm that the information provided on this form is correct, and I have disclosed all the relevant information that might affect my childs health and wellbeing at Seaford College.

I have also ticked the relevant consent boxes above and I am aware I should contact the school nurse if I have any questions relating to any information held in this form. *

Please complete the following forms below for ALLERGIES, ASTHMA and Food Intolerance after you have submitted the forms.  Go back to the medical information menu and select the correct care plan.

Allergy Action Plan - Seaford College (fireflycloud.net)

Asthma Care Plan - Seaford College (fireflycloud.net)

Allergies And Intolerances - Seaford College (fireflycloud.net)

Signature *
Date: *

Thank you for completing your child's medical record form.  If you have any questions or would like to speak to our school nurses please contact us on 01798 867392 or email medicalcentre@seaford.org.

Please leave the next box blank or your submission will not be accepted: