Medical Form - Boarding

General

Pupil's First Name* Pupil's Family Name/ Surname* Pupil's Given Name* Pupil's Address (including postcode)* Year Group (please choose from the list)* Date of Birth* Place of Birth:* Date child will enter the school (eg September 2021)* Previous schools attended* Name of family doctor (GP) Address of family doctor (GP) if lived in the UK before National Health Service Number (NHS)

Has you child ever lived outside the UK?*YesNo

If yes, please state country

All boarding pupils will be registered with the School Doctor’s General Practice.

Immunisation History

All pupils attending this school should be vaccinated against the following diseases before they join the school:

Diphtheria
Measles
Tetanus
Mumps
Polio
Rubella
Meningitis B & C

Please give a full vaccination history with dates of all doses of vaccines given:

	Date	Date	Date	Date
Diptheria
Tetanus
Polio
Whooping Cough
Mumps, Measles & Rubella (MMR)
Typhoid
Cholera
Yellow Fever
Seasonal Influenza Vaccine
Hepatitis A
Hepatitis B
Meningitis C Vaccine
Human Papilloma Virus
Other

Other Medical Issues

Pupil's present weight* Pupil's present height* Has your child, at any time, suffered from any of the following conditions:

	Yes	No	In the past, now recovered
Asthma*
Hayfever
Epilepsy
Recurrent headaches, migraines
Panic attacks
Depression
Emotional or psychological problems
Bed wetting
Diabetes
Eating disorder
Mobility problems
Bone or joint disorder
Visual deficiency
Colour blindness
Hearing deficiency
Recurrent ear infections

* If you answered yes to Asthma, please complete the asthma treatment plan

If you said yes to any of the questions above, please give details

Is your child receiving any medical treatment or attending appointments with a doctor or specialist at present?*YesNo

If Yes, please give further details

Is your child taking any medication or supplement?*YesNo

If Yes, please give further details

Allergies

Please list any known allergies including the symptoms and how the symptoms are resolved in the table below:

	Allergen	Symptoms	Symptoms resolved by

Is your son/daughter prescribed an Adrenalin Auto Injector?*Yes (If yes, please complete the anaphylaxis treatment plan)No

Further Information

Please state any other illnesses, accidents, operations or developmental delay about which you feel the medical staff should be aware.

First Aid Treatment

First aid treatment will be provided as necessary. By signing this form you are providing consent for this to be administered by the School Nursing Staff and / or a qualified first aider.

Dentist

All pupils should continue to be seen at home regularly by their own dentist. Emergency treatment can be arranged locally if required and boarding pupils will be registered with a local dentist for these instances.

Gum Shields

A gum shield is compulsory for all rugby and hockey players.

Registration with GP Practice

Full boarders must register with the local GP service, Ashlea Medical Practice.
Weekly boarders can keep their home GP. However, they must be within a 25 miles radius to the school and is the parent’s responsibility for arranging appointments and for organising the transport to and from the appointment. The school reserves the right to take the pupils to Ashlea Medical Practice as a visiting/temporary patient if deemed necessary.

Consent to treatments

If your child should require special medical treatment, every effort will be made to obtain the prior consent of the parents/guardian or from the child themselves, if 16 years or over. If this is not possible, the Headmaster, a Deputy Head or a Housemaster / Housemistress, acting in ‘loco parentis’, will sign the required authorisation and consent forms following medical consultation for the treatment.

In such circumstances, there will be liaison with parents/guardians, Medical Centre/ Housemasters / Housemistresses / Headmaster, as appropriate. With sensitive medical matters, the Nursing staff will respect your child’s confidence. However, there may be rare occasions when it is considered that it is in your child’s better interest or necessary for the protection of the wider school community that confidence is breached and relevant information is passed to the appropriate person or body. This may include appropriate referrals to relevant professionals.

If your child is unwell or infectious they will be sent home or to their guardian until well enough to return to school. Guardians should live within an hour’s travelling time of the school.

Guardian Name Guardian Address Guardian Home Telephone Work / Day Telephone Guardian Mobile

The School Nursing staff following assessment, can administer boarding students medication from a list of over the counter medication. Prescription only Medication can only be given under the direction of the prescribing Doctor.

The Boarding House Staff may administer ‘over the counter’ medicines to the boarding pupils as per the First Aid Policy* when the Medical Centre is closed.

Any medication brought from home whether it be prescribed, over the counter or herbal, must be registered and stored in the Medical Centre. A *Pupil Medication Request Form* must accompany it. The medicine must be in the original packaging stating generic drug name, dose and the pupil’s name. An English translation must be provided in the case of foreign medicines.

In rare cases a boarding student may be allowed to self-medicate after discussion and assessment by the School Nurse.

You automatically consent to the school nurses administering over the counter preparations (the Medication and Product List* is available on our website). If you do not wish to give this consent, please state this in writing. Once at the school, a parent login will be provided and you will be able to confirm or deny consent electronically.

IMPORTANT: If your child has Asthma please complete an Asthma Treatment Plan* and read the Asthma Policy*. If your child is prescribed an Adrenaline Auto Injector please complete the Anaphylaxis Treatment Plan*. All additional medical forms can be found on our website under ‘Freemen’s Life’ & ‘Medical’ and must be returned with this form.

I have read and accept the above arrangements as part of the conditions of my child’s attendance at the City of London Freemen’s School.

Parent Name* Date* Parent Email*

Thank you for taking the time to complete this form. Please contact the Medical Centre on 44(0)1372 822451 or medical@freemens.org if you wish to discuss any concerns.

City of London Freemen’s School collects medical information regarding your child, so that we can provide them with appropriate support when they join the school. Personal information will be processed and stored in accordance with the Data Protection Act 1998.

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City of London Freemen's School