Medical form
MEDICAL FORM
1. Child’s name _______________________________________________________________
2. School journey to Lake Garda
From: (date/time) 1
st
April To: (date/time) 5
th
April
3. Medical information
i. Name and address of family doctor (GP):
___________________________________________________________________________
___________________________________________________________________________
ii. Child’s date of birth: ___________________________________
iii. Is your child at present under medical supervision or any form of medical treatment?
! Yes ! No
If yes, please give details:
Condition: ____________________________________________________________
Treatment: ___________________________________________________________
Name of hospital attended (if applicable): ___________________________________
If your child is taking any medicines, a supply sufficient to last the visit/journey must
be given to the party leader on or before the departure date, together with written
details of the dosage copy of the doctors prescription form and times of
administration. This applies also to medicines which may be needed only
occasionally. If appropriate, in accordance with medical advice, your child could
manage his/her own medication
iv. Has your child, in the past, suffered from:
Asthma: ! Yes ! No
Hay fever: ! Yes ! No
Epilepsy: ! Yes ! No
Other allergies? (eg. allergies to antibiotics/plasters/food etc) Please provide details:
____________________________________________________________________
____________________________________________________________________
Any serious illness?: ___________________________________________________
v. Have any restrictions been placed on your child’s activities on medical advice?:
a) swimming: ! Yes ! No
b) climbing or using equipment at heights: ! Yes ! No
c) strenuous activities: ! Yes ! No
d) other: _____________________________________________________________
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