Long Crendon | After School Club | Medical Form XYZ Music Academy Music Club Consent Form for Long Crendon School Name of Child * Name of Child First First Last Last Date of Birth * School Year * ReceptionYear 1Year 2Year 3Year 4Year 5Year 6 In an emergency please contact: * Phone * Email * My child may be given the following if needed: * Hypo-allergenic Plasters Non-alcoholic medical wipes Sterile solution for eye irrigation Sun cream (to be applied by the child/ staff) Hay fever and allergy liquid (non-sedating antihistamine medicine) Will your child bring an inhaler? * Yes No Will your child bring an EpiPen? Yes No Has your child ever experienced an allergic reaction to a bite or sting? If yes, please describe the symptoms your child experienced and what triggered the reaction (if known): * Yes No Describe the symptoms your child experienced and what triggered the reaction (if known): * Permissions Are you happy for photos to be taken of your child as a record of their time at Music Club and shared with you? * Yes No Are you happy for us to use photos of your child for publicity of Music Club? * Yes No Please confirm if you are happy for your child to walk home by themselves? * Yes No Please read and tick below: Terms and Conditions * I have read and agree with the Music Club’s cancellation terms and conditions which align with the XYZ Music Academy cancellation policy. I give permission for my child to be treated at Music Club with the medical items I have ticked ‘yes’ for above, and understand that I will be informed of any medical issues that occur in regard to my child. If you are human, leave this field blank. Submit
