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 conditions (including travel sickness), requiring medical treatment?(Required)– please select –YesNoIf yes, please select medical condition– please select –Attention-Deficit/Hyperactivity Disorder (ADHD)Anxiety and depressionArthritisAsthmaAutism Spectrum Disorders (ASDs)Blood ClotsBroken Bone(s)CancerCerebral PalsyCrohn’s DiseaseChronic FatigueMental HealthDiabetesHaemophiliaHepatitisHIV/AIDSHuman Papillomavirus (HPV)Irritable Bowel Syndrome (IBS)Language and Speech Disorders Learning DisordersLupusMeningitisObesityPremenstrual Syndrome (PMS)Seasonal FluSickle Cell DiseaseScoliosisSinus InfectionSore ThroatSTDsTetanusThalassemiaTourette SyndromeUlcersVisual ImpairmentOtherIf 'other' is selected from medical condition above, please give detailsPlease state the current medication and dosageIs it permitted for AB staff members to administer over the counter pain relief(Required)– please select –YesNoIf yes, please select any over the counter pain relief medication NOT to be administered. Paracetamol (for example, Tylenol, Panadol and Calpol®) Aspirin (for example, Anadin) Non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (for example, Nurofen and Calprofen®) Weak opioid painkillers such as codeine and dihydrocodeine – these are usually added to another painkiller such as paracetamol (for example, co-codamol, Paracodol and Paramol) OtherIf any other medication is NOT to be administered, please give brief detailsPlease indicate any known allergy to drugs(Required) NONE Insulin Antibiotics Pain killers General anaesthetics Local anaesthetics OtherIf 'other' is selected from drug allergies above, please give brief detailsPlease indicate any special dietary requirements(Required) NONE Vegetarian Vegan Kosher Halal Gluten-free OtherIf 'other' is selected above for dietary requirements, please give brief detailsPlease indicate any known allergy to foods(Required) NONE Celery Gluten e.g., wheat, rye, oats Fish Crustacean/shelled fish e.g., prawn, crabs, lobster Molluscs e.g., clams, mussels, oysters, scallops Eggs Milk Lupin bean Peanut Sesame Soybean Mustard Sulphur dioxide and sulphites (E220 – E228) Tree nuts e.g., almonds, hazelnuts, walnuts, Brazil nuts, cashews, pecans, pistachios and macadamia nuts OtherSelect AllIf 'other' is selected from food allergies above, please give brief detailsTo 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)– please select –YesNoIf YES, please specifyDate of the student's last tetanus injection(Required) DD slash MM slash YYYY Parent\Legal Guardian Contact InformationPrimary Legal Guardian Contact Name(Required)Relationship to student(Required)Primary Contact Home Tel(Required)Primary Contact Work TelPrimary Contact Mobile Tel(Required)Primary Contact Email(Required) Enter Email Confirm Email Primary Contact Home Address(Required)Secondary Contact Name(Required)Secondary Contact Home Tel(Required)Secondary Contact Work TelSecondary Contact Mobile Tel(Required)Secondary Contact Email(Required) Enter Email Confirm Email Secondary Contact Home Address(Required)MEDICAL CLINICIAN INFORMATIONDoctor's Name(Required)Doctor's Phone Number(Required)Doctor's Address (including postcode)(Required)CONSENT – I hereby authorise the release of the medical information of the above-named student to the appropriate staff member(s). The declaration below constitutes authorisation to perform any emergency treatment during Amos Bursary trips or activities.DECLARATIONI confirm that I am the parent/legal guardian of the above-named student OR I am the above-named student and I am 18 years old or above(Required) YesFull Name(Required)
