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Admissions
Early Years
Overview
Early Years Admissions
Weekend School
Overview
Details
Pre-School
Weekend School Admissions
Teenage Intensive
Overview
Teenage Intensive Admissions
Quran Academy
Overview
Quran Academy Admissions
Events & Activities
Upcoming
Past
Islamic classes, events & activities for under-18s
About Us
Teachers
Vision & Mission
Contact Us
Summer Camp 2019 Medical Questionnaire
Please submit
one
form per child.
Parent/Guardian Name
*
First Name
Last Name
Email
*
Mobile Telephone Number
*
Relationship to Child
*
Parent
Sibling
Aunt/Uncle
Other
Child's Name
*
First Name
Last Name
Child's Gender
*
Male
Female
Child's Age
*
6
7
8
9
10
11
12
Does your child have a medical condition/health concern that needs to be managed during the day?
Select the appropriate box or if not mentioned please specify
Allergies
Asthma
Diabetes
Seizure disorder (e.g. epilepsy)]
Hearing impairment
Physical disability
Speech impairment
Visual impairment
Intellectual/learning impairment (e.g. dyslexia)
Acquired brain impairment
Mental health or behaviour issue (e.g. depression, ADHD)
If other, please specify
If you have ticked any of the boxes above, please provide further information
If the pupil has any special needs/requires extra support, details of previous special needs assessments undertaken by a school etc.
Does your child need to take medication throughout the day?
If yes, please provide details including the medication to be taken and how often:
Does your child have a health care plan that should be followed in a medical emergency?
If yes, please provide details
Emergency Contact 2
*
Must be different to parent/guardian named above
First Name
Last Name
Relationship to Child
*
Parent
Sibling
Aunt/Uncle
Grandparent
Family Friend
Other
Telephone Number
*
Pick-Up Password
*
The teacher will only allow your child to be picked up at the end of the day by an adult who correctly provides the Password. It can be a simple word e.g. animal/colour or something more complex.
Thank you!
