Summer Camp 2019 Medical Questionnaire

Please submit one form per child.

Parent/Guardian Name *
Parent/Guardian Name
Child's Name *
Child's Name
Child's Gender *
Does your child have a medical condition/health concern that needs to be managed during the day?
Select the appropriate box or if not mentioned please specify
If the pupil has any special needs/requires extra support, details of previous special needs assessments undertaken by a school etc.
If yes, please provide details including the medication to be taken and how often:
If yes, please provide details
Emergency Contact 2 *
Emergency Contact 2
Must be different to parent/guardian named above
The teacher will only allow your child to be picked up at the end of the day by an adult who correctly provides the Password. It can be a simple word e.g. animal/colour or something more complex.