MEDICAL FORM

Date of last anti-tetanus injection _________________________

Does your son/daughter suffer from any conditions requiring medical treatment, including medication.                                                                                                             YES / NO 

 If YES, please give precise details (confidential information for the Education Co-ordinator)

_________________________________________________________________

Please indicate the type of pain/flu medication your child may be given if necessary

 _________________________________________________________________

Is your child allergic to medication ?                YES / NO                         ____________________

Does your child have special dietary requirements ?       YES / NO        _____________________

During your child's visit to Ogmore he/she may be involved in group photographs/videos. These may be used in Centre, in promotional literature or on our website.

Signature of Parent or Person with Parental Responsibility _______________________

Relationship to child _______________________________________

Telephone No.  Home_________________________  Work _______________________

Alternative name, address & telephone no. to be contacted in an emergency _________________________________________________________________________

_______________________________  Telephone ______________________

THIS MEDICAL FORM MUST BE BROUGHT TO THE CENTRE.  IT SHOULD NOT BE SENT IN ADVANCE

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