* Required

Contact Details

Student's first namerequired

Student's surnamerequired

Date of birth required (dd/mm/yyyy)

Address 1required

Address 2

Address 3

City

County

Postcode

Country

Email Field

GP namerequired

GP Practice Addressrequired

Address 2

Address 3

City

County

Postcode

Country

In case of emergency contact name required

Relationship

Home or work phone number

Mobile number

Medical Information

Please select one*

Has the student suffered from any significant medical conditions which, for his/her own safety, staff and particularly PE staff, should be aware (e.g. heart condition, diabetes, epilepsy, asthma, eating disorder, or previous injuries including concussion?

Yes No

If yes, please give details

Please attach any relevant letters / documents here:

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Fill in the below if necessary

Please give details of any current regular or emergency medication e.g. salbutamol, insulin and Epipen (including dose and timing)

Allergies

Does the student have allergies to medicines,pollens, foods or stinging insects? (Please give details)

Important Note to Parents

It is the responsibility of you as parent to inform the School Office of any changes to the information provided after this form has been submitted. In addition to medical considerations if treatment is required, any change of circumstance not notified to the school might invalidate the school’s insurance cover for the student.

Should your son/daughter require emergency/hospital treatment, there is a need for the members of staff to demonstrate that they may act in loco parentis. Their first priority would be to attempt to make contact with you by telephone. Should this prove impossible, or the delay involved in obtaining your consent be considered inadvisable by the doctor or surgeon concerned, a member of the Royal Grammar School staff will act on your behalf so far as is reasonable and practicable, and the decision about treatment will be taken by the doctor.

Parents' Statement

I hereby give the Royal Grammar School staff in charge permission to act in loco parentis and to have absolute discretion in the event of emergency medical treatment being deemed necessary for my son/daughter/child for whom I am responsible and to disclose details set out above to members of the medical and emergency services dealing with the case. There are no religious or cultural issues regarding medical treatment for my child.

I give consent for my son/daughter/child for whom I am responsible to participate in all sports provided by the RGS and to represent the school throughout the school year 2019-20, in both home and away fixtures which do not involve an overnight stay.

Signedrequired

Please add your signature into the box

Please print your namerequired

Daterequired (dd/mm/yyyy)

Please provide an email address where we can send a link to your current form.

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