Residential at Ingleborough Hall - Bradford Music Education Hub

Child Full Name *

Instrument *

School *

MEDICAL FORM

Does your child have any conditions requiring medical treatment, including medication? *

Yes
No

If YES, please provide details:

Does your child administer their own medication?

Yes
No

Name and Address of your child's GP *

GP Telephone *

Please outline any special dietary requirements of your child *

Please indicate the type of pain/flu relief medication your child may be given if necessary: *

Is your child allergic to any medication? *

Yes
No

If YES, please provide details:

Does your child have any night time tendencies? e.g. sleep walking (Yes/No - please specify)

Please supply any additional relevant information:

Parent/Carer Contact Information:

Parent/Carer Full Name *

Parent/Carer Contact Email *

Parent/Carer Contact Telephone *

Parent/Carer Mobile *

Parent/Carer Work Telephone *

Parent/Carer Full Address *

Alternative Emergency Contact:

Emergency Contact Full Name: *

Emergency Contact Telephone *

Emergency Contact Mobile *

Emergency Contact Full Address (if different from above)

Declaration

I agree to my child receiving medication as instructed: *

Yes
No

In an emergency I agree to my child receiving medication as instructed: *

Yes
No

In an emergency: I understand that in the case of an emergency every effort will be made to contact myself or the named alternative contact. However, if it becomes necessary for my child to receive medical treatment and I cannot be contacted by telephone or any other means to authorise this, I hereby give my general consent to any necessary medical treatment and authorise designated Music & Arts Service staff to sign any document required by the hospital authorities.

CODE OF CONDUCT

Please read the below documents relating to the Code of Conduct.

I agree to the Terms of the 'Code of Conduct' outlined *

I agree