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This form is to be completed for all Amos Bursary students. Where the student is 18 years or over they may complete it themselves. Where the student is under 18 years it must be completed by a parent or legal guardian.
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Any medical conditions, YES / NO (including travel sickness, requiring medical treatment, details of medication taken)
Food Allergies
Please outline any special dietary requirements of your child and the type of pain/symptom relief medication your child may be given if necessary
Allergy
Relief and\or medication required
 
Any other special dietary requirements?
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Primary Emergency Contact
Primary Contact Email(Required)
Alternative Emergency Contact
Alternative Contact Email(Required)
Family Doctor
I agree to receive or to my child/ward receiving medication as instructed and any emergency dental, medical or surgical treatment, including anaesthetic or blood transfusion, as considered necessary by the medical authorities present. I understand the extent and limitations of the insurance cover provided.
I confirm that I am:(Required)
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