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.
DD slash MM slash YYYY
If yes, please select any over the counter pain relief medication NOT to be administered.
Please indicate any known allergy to drugs(Required)
Please indicate any special dietary requirements(Required)
Please indicate any known allergy to foods(Required)
DD slash MM slash YYYY
Parent\Legal Guardian Contact Information
Primary Contact Email(Required)
Secondary Contact Email(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.
I 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)