Please note: This form is for short course students only. Short Stay Medical Form Step 1 of 2 - Dear Parent 50% This form MUST be completed in English. Medical contract with parent/guardian Name of the student* First Last Gender*MaleFemaleEthnic Category*White- English, Welsh, Scottish, Northern Irish or British- Irish- Gypsy or Irish Traveller- Any other White backgroundMixed or Multiple ethnic groups- White and Black Caribbean- White and Black African- White and Asian- Any other Mixed or Multiple ethnic backgroundAsian or Asian British- Indian- Pakistani- Bangladeshi- Chinese- Any other Asian backgroundBlack, African, Caribbean or Black British- African- Caribbean- Any other Black, African or Caribbean backgroundOther ethnic group- Arab- Any other ethnic groupOther Ethnic Group (please specify)* Date of Birth* DD slash MM slash YYYY Home Country* Start Date* DD slash MM slash YYYY Your Admissions Representative at Buckswood* Lisa Jane Davies (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) Nurse: Michael Collinson, Health Care Assistant: Fatima Nahoor. Phone: 01424 813813 – Ext 251,Email: nurses@buckswood.co.uk Does your child have a European Health Insurance Card (EHIC)*YesNoHave you arranged medical insurance for the entire stay?* Yes No Does your child have any allergies? (Please give details)*Date of last tetanus vaccination* 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* MM slash DD slash YYYY Signature*Consent* I agree to the privacy policy.Please make sure you check your 'spam' or 'junk' folder as the receipt message sometimes finds its way in there. Further Information School Prospectus Subject Overview Subject (Science, English, Maths) Overview Apply Now