FORM Medical Consent Parent/Guardian's name* Parent/Guardian's email address* Child's name* Gender* Male Female Child's year group*Please selectYear 7 (Remove)Year 8 (Inters)Year 9 (Lower Transits )Year 10 (Upper Transits)Year 11 (Shell)Year 12 (Study I)Year 13 (Study II)Date today* DD slash MM slash YYYY Child's blood group Child's NHS number Please tick if your child: has suffered from any significant illness or had any operations is currently receiving treatment or suffering from any condition If you have ticked either of the boxes above, please provide details:Does your child have any known allergies?Please selectYesNoIf yes, what kind of allergy? Please give information on how this allergy is usually treated: Epi-pen Inhaler Cetirizine If you have ticked 'Cetirizine' above, you will need to bring your own anti-histamine supply, which has to be declared to Miss Mialkowski (ashleigh.mialkowski@wychwoodschool.org) in writing via email with instructions in English and labelled with your name. Child's town and country of birth Current doctor's name and surgery address Please indicate which of the following immunisations your child has had and provide the date for each one: DTaP/IPV/HIB (diphtheria, tetanus, pertussis, polio and Hib) 1st dose 2nd dose 3rd dose Date for each dose of DTaP/IPV/HIBHepatitis B 1st dose 2nd dose 3rd dose booster Date for each dose of Hepatitis BMeningitis B 1st dose 2nd dose 3rd dose Date for each dose of Meningitis BPCV (prevention of pneumococcal disease) 1st dose 2nd dose 3rd dose 4th dose Date for each dose of PCVRotavirus 1st dose 2nd dose Date for each dose of RotavirusHib (prevention of Haemophilus influenzae) 1st dose booster Date for each dose of HibMeningitis C 1st dose booster Date for each dose of Meningitis CMMR (measles, mumps, rubella) 1st dose 2nd dose Date for each dose of MMRPre-school booster DTaP/IPV (diphtheria, tetanus, pertussis, polio) booster Date for the pre-school booster of DTaP/IPVHPV 1 (human papillomavirus - prevention of cervical cancer) 1st dose Date for the 1st dose of HPV 1HPV 2 (human papillomavirus - prevention of cervical cancer) 2nd dose Date for the 2nd dose of HPV 2Td/IPV booster (tetanus, diphtheria, polio) booster Date for the Td/IPV boosterMenACWY (Protection against Meningococcal bacteria types A, C, W and Y) 1st dose Date for the dose of MenACWYBCG (tuberculosis) 1st dose Date for the dose of BCGCOVID-19 1st dose 2nd dose booster Date for each dose and booster of COVID-19Flu Annual dose Date for dose of FluPlease give any details and dates of any other vaccinations:I give my permission for a qualified First Aider to administer first aid as necessary. Yes No In the case of emergency, I consent to medical, dental and optical treatment being given. (NB Parents are always contacted wherever possible.) Yes No For day pupils, please tick the boxes if you permit us to administer any of the following as required: Paracetamol Calpol Six Plus (paracetamol suspension) Throat sweets (Strepsils) Antiseptic cream (Savlon) Burns treatment Bites and sting cream (Eurax) Hypoallergenic plasters For boarders, please tick the boxes if you permit us to administer any of the following as required: Paracetamol Calpol Six Plus (paracetamol suspension) Ibuprofen (12+) Ibuprofen gel Nurofen for Children (ibuprofen suspension) Throat sweets (Strepsils) Antiseptic cream (Savlon) Sore throat gargle (diluted TCP) Burns treatment Bites and sting cream (Eurax) Arnicare (homeopathic cream for bruises and swelling) Antihistamine tablets (Cetirizine) Hypoallergenic plasters Please tick the box to confirm you understand that any medication brought into school has to be declared to Miss Mialkowski (ashleigh.mialkowski@wychwoodschool.org) in writing detailing what the medication is for and instructions.* I confirm
