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This form includes sensitive Information and must be treated as confidential

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* 1. Child's Name

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* 2. Child's Date of Birth  DD/MM/YYYY

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* 3. Medical Diagnosis/Condition/Allergy (Please provide as much information as you can)

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* 4. Date of Diagnosis/Condition/Allergy

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* 5. If applicable, next review date of Diagnosis/Condition/Allergy

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* 6. Clinic/Hospital

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* 7. Telephone Number

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* 8. I have emailed a copy of a medical letter to confirm condition/diagnosis/allergy to admin@caltonprimary.co.uk

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* 9. Describe medical needs and give details of child's symptoms, triggers, signs, treatments, facilities, equipment or devices, environmental issues etc.

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* 10. Name of medication, dose, method of administration, when to be taken, side effects, contradictions, administered by / self administered with/without supervision, if applicable

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* 11. Special arrangements for school visits/trips if applicable

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* 12. Any other information you feel the school may need

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* 13. Name of Parent/Carer completing this form

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* 14. Relationship to Child 

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