Please enable JavaScript in your browser to complete this form.Medical Information - Step 1 of 2Medical and Personal Care Disclosure FormA normal signature will requested on the first day of your child starting with Chudleigh Pre-School.Child’s full name (hereafter referred to as ‘child’): *FirstLastChild's Address *Address Line 1Address Line 2CityState / Province / RegionPostal CodeDoes your child have any dietary needs or allergies or food intolerances: *YesNoIf yes, please give details:What drink would s/he prefer? *MilkWaterEitherDoes your child have any special needs including; wearing glasses, speech therapy, any major illness/operations, or any on-going health problems e.g. glue ear, asthma: *Is your child up-to-date with all of the immunisations offered? *YesNoIf No, please give details:Has your child ever had a febrile convulsion? *YesNoChild’s Doctor’s name: *FirstLastDoctor's Address *Address Line 1Address Line 2CityState / Province / RegionPostal CodeTelephone number:Child’s Health Visitor’s name:FirstLastChild’s Health Visitor’s address if different from above:Address Line 1Address Line 2CityState / Province / RegionPostal CodeI expressly consent to Chudleigh Pre-school seeking any necessary emergency medical advice or treatment in respect of my child. I confirm that the above information is correct.Signature of Parent/Guardian and Date *Signature of Parent/Guardian and DateNappy changing/toilet useI give permission for the staff of Chudleigh Pre-school to assist my child with any nappy changing and/or toileting needs *YesNot ApplicableSignature of Parent/Guardian and Date *NextGiving Paracetamol to your childIf your child is unwell whilst in our care, we will contact you and ask you to come and collect your child as soon as possible. Occasionally in these instances, a child could have a temperature which could increase rapidly; paracetamol (eg Calpol) could help manage the temperature. In this instance the following procedure would be followed:In this instance the following procedure would be followed:****A Pre-school staff member trained in paediatric first aid would monitor and record the child's temperature every 10 minutes. *****Noting that the temperature is increasing the staff member would speak to the parent concerned and explain the situation. They would ask the parent's permission to administer paracetamol and check with the parent if the child had taken any other medication recently.The correct dose of paracetamol would be administered only if at this time a parent gives verbal consent and confirms no other medication had been taken which could interfere with the paracetamol and when written consent is already on file.I consent to my child receiving paracetamol (eg Calpol) according to the above procedure; (each 5ml of the medication contains 120mg Paracetamol.)In this instance the following procedure would be followed: (copy) (copy)****A Pre-school staff member trained in paediatric first aid would monitor and record the child's temperature every 10 minutes. *****Noting that the temperature is increasing the staff member would speak to the parent concerned and explain the situation. They would ask the parent's permission to administer paracetamol and check with the parent if the child had taken any other medication recently.The dose (ML) for my child is: *Signed and Dated *Giving antihistamine to your childIf your child is unwell whilst in our care, we will contact you and ask you to come and collect your child as soon as possible. Occasionally in these instances, a child could have a mild allergic reaction in which case an antihistamine (eg. Loratadine 5mg) could help manage the symptoms.In this instance the following procedure would be followed: *****A Pre-school staff member trained in paediatric first aid would monitor the child. *****Noting symptoms the staff member would speak to the parent concerned and explain the situation. They would ask the parent's permission to administer the antihistamine syrup and check with the parent if the child had taken any other medication recently. *****The correct dose of antihistamine syrup would be administered only if at this time a parent gives verbal consent and confirms no other medication had been taken which could interfere with the medicine written consent is already on file.In the case of real concern (eg anaphylactic shock) staff would call 999 as well as the parent. *I consent to my child receiving an antihistamine syrup (eg Loratadine 5mg – recommended dose is 5ml for children aged 2 – 12 years under 30kg) according to the above procedure;I do not consent to my child receiving an antihistamine syrupThe dose (ml) for my child is: *Signed and Dated *Consent to apply Sun Cream FOR CHILDREN STAYING FOR A FULL DAYI give permission for the staff at Chudleigh Pre-school to apply 'Solero Kids SPF 50+ Ultra Sensitive' sunlotion (UV-A and UV-B) to my child at the end of the morning session.I give permission for the staff at Chudleigh Pre-school to apply sun cream to my child at the end of the morning session. I am providing a named bottle of sun cream for my child for this purpose.Signed and Dated *PreviousCommentSubmit