Section 1 Child/Young Persons details:

    Is your child in:

    Date of Birth

    Home Address:

    Name of GP Practice

    Name of GP

    GP Telephone Number

    Details of any known medical conditions, allergies, disabilities etc. e.g asthma, diabetes, epilepsy, ASD and any medication being taken (inc. doses and frequency)

    Will she carry medicine at GB Yes/no

    If unwell is she able to administer the medication herself Yes/No

    If no do you give permission for the leader in charge/first-aider to give her this medication? Yes/no

    Does your young person have any other special needs, requirements or directions that would be helpful for leaders to know

    Is your young person a

    Section 2 Parent/Guardian Details


    Relationship to Child

    Contact No.