HEALTH FORM UNDER 18S
PLEASE PRINT AND ENSURE EACH PARTICIPANT COMPLETES THE FOLLOWING DOCUMENT ANY ISSUES ARE TO
BE RECORDED UNDER SPECIAL REQUIRMENTS (GROUP OVERVIEW) PLEASE PDF ALL FORMS AND EMAIL AS A
COMPLETED PACK
ISSUE 1-Jan 2014
PERSONAL INFORMATION
Surname
Given Name(s)
MEDICAL HISTORY: CHECK THE ONES THAT APPLY TO YOU & DESCRIBE
ADD/ADHD
Headaches
Anxiety/Panic attack
Hearing Problems
Asthma
Heart Condition
Bee Sting allergy
Kidney/urinary
Bowel problem
Muscle Disorder
Neurological
Cerebral Palsy
Concern
Diabetes
Orthopaedic problem
Color Blindness
Seizures
Epi-Pen
Vision problems
Emotional Concerns
Other
ALLERGIES: LIST OF ALLERGIES/INTOLERANCES
1. Cause
Treatment
2. Cause
Treatment
MEDICATION: (INCLUDE PRESCRIPTION, OVER-THE-COUNTER AND HERBAL
MEDICATION.)
1. Name
Treatment
2. Name
Treatment
LIST ANY PAST OPERATIONS, INJURIES, MAJOR ILLNESSES, OR HOSPITALIZATIONS AND
GIVE DATES
Is there any reason why you can not take part in sport/activities? YES/NO
If YES, please specify
HAS YOUR CHILD HAD ANY OF THE FOLLOWING: IF YES PLEASE SPECIFY AT WHAT
AGE OR THE DATE AFFECTED
Chicken Pox
Mumps
Diphtheria
Rehumatic Fever
Malaria
Scarlet Fever
Measles/German
Whooping Cough
Measles
Meningits
Other
OTHER INFORMATION
YES, please specify
Is there any reason why you can not take part
in sport/activities?
Does your child wear contact lens / Glasses
Does child sleep-walk, wet the bed, have poor
bladder or bowel control?
NO
HEALTH FORM UNDER 18S
Does child have any problems with hearing
Does child require a special diet?
Permission for Emergency Medical Treatment:
In the event of an emergency (medical or natural disaster) during the stay and I/we cannot be contacted, I
give my permission for the NW Academy of English staff member in charge of medical care to give and/or
authorize emergency medical treatment for my son/daughter. I also give my permission to transport my
son/daughter to a medical treatment center if needed.
Medication
We cannot be responsible for medicines which are not recognized in the UK and which are not clearly
labeled in English. Pupils who take prescribed medication should bring a letter from their doctor or the
prescriber. This medication and any personal ‘over the counter’ (OTC) medicines must be given to the
Houseparent or Matron. It is not appropriate for your son/daughter to keep OTC medicine for their own
use.
Insurance
NW Academy recommends parents/guardians/agents/sending organizations to purchase an Insurance that
includes: personal accident or injury, private medical, personal belongings, delayed or lost luggage,
money, emergency replacement passport, cancellation, travel delay, missed departure, personal liability.
Please fill in insurance details (if applicable). This information will be treated as confidential.
Name of insurance company
Name of Subscriber
Policy number
This information will be treated as confidential.
Parent/ Guardian Print Name and
Surname
Parent/ Guardian Signature
Date