HiddenLead SourceHiddenCompanyThis 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.Student's First Name(Required)Student's Last Name(Required)Date of Birth(Required) DD slash MM slash YYYY Any medical conditions, YES / NO (including travel sickness, requiring medical treatment, details of medication taken)If YES, please give brief details:Please outline any special dietary requirements of your child and the type of pain/symptom relief medication your child may be given if necessary:(Required)Food AllergiesPlease outline any special dietary requirements of your child and the type of pain/symptom relief medication your child may be given if necessaryAllergyRelief and\or medication required Add RemoveIs your son/daughter allergic to any medication?(Required)YesNoAny other special dietary requirements? Diabetic Vegetarian Vegan Kosher HalalOther (please specify)To the best of your knowledge, in the last four weeks, has the student been in contact with any contagious or infectious diseases or suffered from any health issue that may be contagious or infectious?(Required)YesNoIf YES, please specify:Date of the student's last tetanus injection?(Required) DD slash MM slash YYYY Primary Emergency ContactPrimary Contact Name(Required)Primary Contact Home Tel:(Required)Primary Contact Work Tel:(Required)Pri Contact Mobile Tel:(Required)Primary Contact Email(Required) Enter Email Confirm Email Primary Contact Home Address(Required)Alternative Emergency ContactAlternative Contact Name(Required)Alternative Contact Home Tel:(Required)Alternative Contact Work Tel:(Required)Alternative Contact Mobile Tel:(Required)Alternative Contact Email(Required) Enter Email Confirm Email Alternative Contact Home Address(Required)Family DoctorDoctor's Name(Required)Doctor's Phone Number(Required)Doctor's Address(Required)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) 18 years old The parent/legal guardian of the above-named childFull name: (capitals)(Required)Date Completed(Required) DD slash MM slash YYYY
