St Neot's Emergency Contact Form 2011/12
Please click on the Submit button at the end of the form after completion.

Personal Details
Surname -	Date of birth
First name(s) -
Name by which your child is known -
Parent(s) name(s) -

Emergency Contact

Address No. 1

House no./Street -

Town -

County -

Post code -

Address No. 2 (if applicable)

House no./Street -

Town -

County -

Post code -

Phone Numbers
Mum home -	Dad home -
Mum work -	Dad work -
Mum mobile -	Dad mobile -
E-mail address -	2nd e-mail -
In the event that the school is unable to contact you on the above numbers, please provide an alternative:
Name of contact -	Relationship -
Phone number(s) -

Dietary Requirements

Please give details of any know food allergies (e.g. nuts, diary products etc) or if your child is unable to eat certain foods for medical, religious or ethical reasons.

Food allergies -

Food products unable to be eaten -

Medical Consent
By clicking on Submit at the bottom of this form, I hereby consent for my child to be given any medication they may require for injury/illness (prescribed, non-prescribed or complementary). I understand that in the event of an emergency every effort will be made to obtain my consent for any emergency intervention, medical or dental. If this proves impossible, I hereby authorise the School Nurse in charge/qualified substitute, the Headmaster or Boarding House Parents to act in loco parentis.
Name of Family Doctor -
NHS number
Surgery address -
Town -
County -
Post code -
Phone number -
Name of Family Dentist -
Has your child had any serious illnesses or operations?	Yes No
	If yes, please provide details:

Medical Conditions

Does your child have problems with any of the following (please give details):

Sight{vision / problem with colours} / Glasses -

Asthma -

Allergies {hayfever / food / medicines} -

Hearing -

Physical disabilities -

Other medical conditions (please specify)-

Name:
 Age: