Medical Needs Form

Child's Name:*

Date of Birth:*

Nursery Child Attends*

Parent/Carer Name:*

Parent/Carer Phone Number:*

Parent/Carer Alternative Phone Number:

Emergency Contact Phone Number:*

Emergency Contact Alternative Phone Number:

GP Name & Practice:*

Phone*

Other relevant medical practitioner details:

My child's medical diagnosis or condition is:*

Please detail usual symptoms and/or reactions or restrictions that present / are in place:*

What actions should be taken when a reaction has taken place?*

Who should be contacted when a reaction has taken place?*

Contact Number*

Additional Information that may be relevant to my child's medical diagnosis or condition:

How does my child's medical diagnosis or condition need to be taken into consideration when at nursery?

Other Information:

Including discharge from specialists, due review, etc

Supporting Documentation*

I understand that I need to provide supporting documentation from my medical practitioners and will do so immediately

Consent & Agreement*

I agree to the staff at Early Start Education Ltd taking responsibility and providing medical intervention in the event of a medical emergency.

I consent to any emergency treatment that may be necessary if, in the opinion of a medical practitioner (ie paramedic) my child is taken to accident and emergency (or any other appropriate medical facility) and once there, provided that in the opinion of the doctor or dentist, that any delay to obtain my signature may endanger my child’s health or safety

Parent/Carer Name

Nursery Medical Needs Awareness Protocol for Children