New Student Application Form and Medical Information

New Student Application Form WITH MEDICAL

STUDENT APPLICATION FORM (For Assessment/entry to NCW) Please complete all sections in full

"*" indicates required fields

Step 1 of 10

Student Name*

Forename Surname

Parent / Carer / Guardian Details

Your name (First Parent/Carer/Guardian)*

Prefix First Last

Relationship to child

Your Email Address*

Enter Email Confirm Email

Your telephone number

Land line

Alternative Telephone Number (Eg Work Number)

Mobile Phone Number*

Your Address*

House name or number Address Line 2 City County Post Code Country

Second Parent/Carer/Guardian Name

Prefix First Last

Relationship to child with vision impairment

Second Parent/Carer/Guardian Email

Second Parent/Carer/Guardian Telephone Number

Second Parent/Carer/Guardian Alternative Telephone Nuumber

Eg Work Number

Second Parent/Carer/Guardian Mobile Telephone Number

Second Parent/Carer/Guardian Address (if different from above)

House Name or number Address Line 2 City County Post Code Country

Who will be our Primary Contact (please check one box)*

Just First Parent/Carer/Guardian

Both first and second Parent/Carer/Guardians

Where did you first hear about NCW?*

Medications

This section seeks to ascertain your child's other medical needs. Please give as much detail as possible, listing ALL conditions, referrals, medications (including over the counter remedies) and dosages that are current or historical. Medications - To ensure safe practice when receiving and administering medication, the college surgery needs to have sight of the original of your child's prescription that is given to them when they have repeat prescriptions, either by their doctor or the pharmacist. If your child is currently on any medication can you please send by post for the attention of 'NCW Wellbeing Hub' an original prescription for our reference.

Ears (including hearing loss)*

Please give information: Is the condition past or current? Medications? Are these self administered? Any medical specialists and how often they are seen?

Heart*

Please give information: Is the condition past or current? Medications? Are these self administered? Any medical specialists and how often they are seen?

Lungs*

Please give information: Is the condition past or current? Medications? Are these self administered? Any medical specialists and how often they are seen?

Kidneys*

Please give information: Is the condition past or current? Medications? Are these self administered? Any medical specialists and how often they are seen?

Diabetes*

Please give information: Is the condition past or current? Medications? Are these self administered? Any medical specialists and how often they are seen?

Asthma*

Please give information: Is the condition past or current? Medications? Are these self administered? Any medical specialists and how often they are seen? Please answer N/A if not applicable

Epilepsy*

Please give information: Is the condition past or current? Medications? Are these self administered? Any medical specialists and how often they are seen? Please answer N/A if not applicable

Eczema*

Please give information: Is the condition past or current? Medications? Are these self administered? Any medical specialists and how often they are seen? Please answer N/A if not applicable

Orthopaedic / Bones*

Please give information: Is the condition past or current? Medications? Are these self administered? Any medical specialists and how often they are seen?

Any other physical medical information*

Please give information: Past or current conditions Medications? Are these self administered? Any medical specialists and how often they are seen?

Dentist

We recommend that your child is registered with a dentist local to home; please provide details below. NCW does not register your child with an optician local to NCW or arrange optician's appointments. This is the parent's responsibility and we would expect they are checked annually unless otherwise indicated by a medical professional. We will arrange emergency dental treatment if required urgently.

Dentistry*

Please give information: About any past or present dentistry considerations. Medications? Are these self administered? Any medical specialists and how often they are seen?

Please give details of Dentist*

Allergies

Please note - We are a nut free campus to protect students who have allergies. Parents are requested to ensure that no nut products are sent into school in tuck boxes or bags,

Allergies*

Please give information: Any allergies - food, medicines, animals, hayfever, pollen etc Medications? Are these self administered? Any medical specialists and how often they are seen? Please answer N/A if not applicable

MEDICAL CONSENT FORM

These consents are valid for the whole of your child's time at NCW. It is your responsibility to inform us of any changes. Your child should remain registered with their current GP unless we agree otherwise with you.

Details of current GP*

Name of Practice, name of doctor, address and telephone number

Emergency Consent*

I give consent for any medical treatment, including surgery and/or anaesthetic, in an emergency situation as recommended by a qualified medical practitioner

I consent to my child being treated with non-prescribed medication, eg Paracetamol, Ibuprofen, cough linctus, throat lozenges, Gaviscon, anti-histamine, bite and sting spray, TCP, Sudocrem and ice packs (these are kept in surgery and the houses)

I consent to my child receiving first aid treatment in the event of an accident

I consent for my child's medical information to be available to a designated person when on activities

I consent to NCW making direct contact with any medical specialists detailed above if required

Name of Student*

First Last

Name of person giving consent with parental responsibility*

First Last

Date*

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