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Student Safety Form

Select the course/s you have booked(Required)

11 Plus foundation course

11 Plus revision course

Stage 1 creative writing course

Stage 2 creative writing course

Gcse revision course

A level revision course

Student name(Required)

First Last

DOB(Required)

DD slash MM slash YYYY

Recent illness (if not applicable write none)(Required)

Current medical condition (if not applicable write none)(Required)

Current medication, including inhaler or EpiPen (if not applicable write none)(Required)

Medication your child will need to take during the course (if not applicable write none)(Required)

11+ & Creative writing courses only: Medication must be handed to Maria or Debbie in a bag or box with your child's name and instructions clearly labelled on the outside. Medication must NOT be left in your child's bag.

All allergies including food, medicine or other (if not applicable write none)(Required)

Medical issues not already mentioned (if not applicable write none)(Required)

Can your child have "Germolene Antiseptic cream" for minor cuts or stings?(Required)

Special Needs including medical, mobility, emotional or educational (if not applicable write none)(Required)

Emergency contact 1

Name(Required)

First Last

Phone(Required)

Email

Relationship to student(Required)

Emergency contact 2

Name(Required)

First Last

Phone(Required)

Email

Relationship to student(Required)

Anything else you need to tell us (if not applicable write none)(Required)

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