Altrincham Grammar School for Boys

Our aim is to ensure that all children with medical conditions are properly supported in school so that they can play a full and active role in school life, remain healthy and achieve their academic potential. We therefore ask that you complete this form carefully so that we can fully support your child if and when needed.

There are 6 sections on this form:
1. Child Information – Compulsory
2. Medical Conditions / Diagnosis – Compulsory
3. Medications – Optional (must be completed if your child may / will need to take medication during school activities in or out of school)
4. Equipment and resources – Optional
5. Specialist / Consultant Information – Optional
6. Parent / Carer Details and Declaration - Compulsory

Please refer to our school policies page for Asthma, Anaphylaxis and Medical Policies as they contain important information on our procedures. (e.g. any child with Asthma MUST always carry their inhaler with them at all times). Policies Page

Information and Permissions Form

CHILD'S INFORMATION

Forename:* Surname:* Date of Birth:* Child's Address:* Post Code:*

CONDITIONS / DIAGNOSIS

Please complete this section with details of any medical conditions that the school needs to be aware of eg. Asthma, Diabetes, Allergies, Hearing loss etc.

You can enter up to 3 medical conditions in this section.Should your child have more than 3, please tick here and we will contact you to obtain the additional information.

Complex Medical NeedsPlease tick If your child has complex medical needs that require specific medical interventions. We will contact you separately for additional information (e.g. Catheterisation, suction / tracheostomy care, personal care, mobility support):

Condition 1.

Name of Condition / Diagnosis:*

Severity of Condition:*MildModerateSevere

Symptoms:* Treatment (e.g. name of medications, uses an insulin pump, give other examples) Please ensure you detail any potential emergency situations and the actions to be taken:*

Do you have an individual Health Care Plan for this condition?*YesNo

Does this condition require regular medical appointments (e.g. physiotherapy):*YesNo

How does this effect day to day life at school (e.g. mobility issues etc, need to go to the toilet more regularly, conditions worsens with physical activity):

Condition 2.

Name of Condition / Diagnosis:

Severity of Condition:MildModerateSevere

Symptoms: Treatment (e.g. name of medications, uses an insulin pump, give other examples) Please ensure you detail any potential emergency situations and the actions to be taken:

Do you have an individual Health Care Plan for this condition?YesNo

Does this condition require regular medical appointments (e.g. physiotherapy):YesNo

How does this effect day to day life at school (e.g. mobility issues etc, need to go to the toilet more regularly, conditions worsens with physical activity):

Condition 3.

Name of Condition / Diagnosis:

Severity of Condition:MildModerateSevere

Symptoms: Treatment (e.g. name of medications, uses an insulin pump, give other examples) Please ensure you detail any potential emergency situations and the actions to be taken:

Do you have an individual Health Care Plan for this condition?YesNo

Does this condition require regular medical appointments (e.g. physiotherapy):YesNo

How does this effect day to day life at school (e.g. mobility issues etc, need to go to the toilet more regularly, conditions worsens with physical activity):

MEDICATIONS

Do any of your child's condition require medication that they may need to take during the school day:*Yes - Please complete this section.No - Please move onto the next page.

Please note, it is the parents'/carers' responsibility to ensure they provide the school with sufficient, in date medication and replacements prior to expiration.

MEDICATION 1.

Name of Medication: For which condition is this medication required?: Time / When administered: Dosage: Side effects: Other useful information:

My child will carry this medication with them at all times (independently and safely) and will administer it themselves (i.e. Asthma Inhaler, Antihistamines for mild allergic reactions etc.):YesYes - but will / may need held and support to take medicine (especially in an emergency situation)No - I would like the school to hold the above medication for my child to collect and will administer it themselves

I would like the school to keep spare medication in case of emergency:YesNo

Please note for AAI users (e.g EpiPen) - Spare medication MUST be kept in school
For Children with Moderate to Sever Asthma we strongly recommend a spare inhaler be kept in school

MEDICATION 2.

Name of Medication: For which condition is this medication required?: Time / When administered: Dosage: Side effects: Other useful information:

My child will carry this medication with them at all times (independently and safely) and will administer it themselves (i.e. Asthma Inhaler, Antihistamines for mild allergic reactions etc.):YesYes - but will / may need held and support to take medicine (especially in an emergency situation)No - I would like the school to hold the above medication for my child to collect and will administer it themselves

I would like the school to keep spare medication in case of emergency:YesNo

Please note for AAI users (e.g EpiPen) - Spare medication MUST be kept in school
For Children with Moderate to Sever Asthma we strongly recommend a spare inhaler be kept in school

MEDICATION 3.

Name of Medication: For which condition is this medication required?: Time / When administered: Dosage: Side effects: Other useful information:

My child will carry this medication with them at all times (independently and safely) and will administer it themselves (i.e. Asthma Inhaler, Antihistamines for mild allergic reactions etc.):YesYes - but will / may need held and support to take medicine (especially in an emergency situation)No - I would like the school to hold the above medication for my child to collect and will administer it themselves

I would like the school to keep spare medication in case of emergency:YesNo

Please note for AAI users (e.g EpiPen) - Spare medication MUST be kept in school
For Children with Moderate to Sever Asthma we strongly recommend a spare inhaler be kept in school

EQUIPMENT / RESOURCES

Do any of your child's condition require equipment or resources that they may need during the school day e.g. Lancets/Food for Diabetics, Mobility Aids etc.*Yes - Please complete this section.No - Please move onto the next page.

Please detail any addition equipment / resources that your child may need to use while in school and what medical condition this relates to:

My child will carry any equipment / resources with them at all times (independently and safely) detailed above.:YesNo

I would like school to hold any equipment / resources for my child to collect and administer independently:YesNo

I would like school to hold any equipment / resources for my child to collect and administer independently but under the supervision of a member of staffYesNo

Specialist / Consultant

Does your child have a Hospital / Clinic consultant / Specialist Nurse:*Yes - Please complete this section.No - Please move onto the next page.

Hospital / Clinic consultant / Specialist Nurse: Name: Position: Based at: Phone Number: Please add any additional Specialist/Consultant Information here:

PARENT / CARER DETAILS

PARENT/CARER 1:

Full Name:* Contact Telephone No.:* Email Address 1:* Relationship to the Child:*

PARENT/CARER 2:

Full Name: Contact Telephone No.: Email Address 2: Relationship to the Child:
PARENT / CARER DECLARATION
Please read the following:
The information I have provided is to the best of my ability, up to date and accurate about my child's current medical needs.
The school may inform the School Nursing Service about my child's needs (if the service is not already aware).
If I have indicated that school may / will be administering the medication, I consent to staff doing so or carrying out the medical intervention in accordance with the school medical policy and sharing relevant information with staff.

I undertake to ensure that the school has adequate supplies of stated medicine(s) or resources required to administer the stated medical intervention(s)

I am happy for the school to contact me to discuss any of the above information.

I agree to inform school of any changes in medical needs or medication / resources / equipment immediately and in writing.

I confirm I have read and understood the above declaration.*Confirmed