Short Stay Student: Medical Form

This form MUST be completed in English.
Medical contract with parent/guardian
Name of the student*
First Last
Gender*
Date of Birth*
Date Format: DD slash MM slash YYYY
Home Country*
Start Date*
Date Format: DD slash MM slash YYYY
Your Admissions Representative at Buckswood*
- Samantha Pugh (UK Admissions)
- Olga Nalivkina (International Admissions)
- Cristina Terrazas (International Admissions)
- Yu Hao (Phoenix) (International Admissions)
- Kyoko Field (International Admissions)
- Sherene Zouehid (International Admissions)
- Unsure of the representative in charge
If you have any questions, please feel free to contact us:

Buckswood Health Service (BHS) Nurses: Louise McCarthy and Maxine Garry, Administrator: Nicole Trevett

Phone: 01424 813813 – Ext 251,Email: nurses@buckswood.co.uk

Does your child have a European Health Insurance Card (EHIC)*
Have you arranged medical insurance for the entire stay?*
- Yes
- No
Does your child have any allergies? (Please give details)*
Date of last tetanus vaccination*
Date Format: DD slash MM slash YYYY
Does he/she have any of the following conditions if so, please include further details including date of diagnosis and any treatment or medication prescribed?
Epilepsy*
Diabetes*
Asthma*
Hayfever*
Other Medical Conditions: (If none, please write N/A)*
Does your child require a special diet? (Please give details)*
If your child needs any medication, we will provide it. Please do not send your child with any medication unless it has been prescribed by a doctor, they will not be permitted to use it.
Please give details of any medically prescribed medication (name, reason for using it and dose).*
Is there anything else we should know about to help your child whilst we are looking after them e.g. family bereavements, emotional problems.*
By signing this you are agreeing to qualified school and NHS staff giving appropriate medicines, medical treatment and First Aid in accordance to the School’s Administration and Management of Medicines Policy.
I agree and confirm the information provided is correct*
- Yes, I understand
Name of parent/guardian signing*
First Last
Parent/Guardian Email Address*
Date*
Date Format: MM slash DD slash YYYY
Signature*
Consent*
I agree to the privacy policy.
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Please note: This form is for short course students only.