Taster Day Pupil Indemnity Form

Child's Full Name* Child's Date of Birth* Please give details of all medical conditions/ailments/illnesses that your child currently has, or previous conditions that the school should be aware of:* If your child is currently taking medication, please give details below: If your child will need to have medication administered in school, or medication kept in school (e.g. an inhaler), please give details below. You will be required to complete an additional medication form. Please give details of any dietary requirements for your child (e.g. vegetarian).* Please list any food allergies or intolerances your child has. Parent/Guardian telephone number(s):*

In the event of the school being unable to contact parent/guardians, please give contact details of two people who will act "in loco parentis".

Name, relation to child and phone number of 1st emergency contact* Name, relation to child and phone number of 2nd emergency contact*

The above information is accurate and correct to the best of my knowledge.

Signed*