Priority One Medical Form

The information below is requested to assist in the event of an accident or illness. This information will be held in strict confidence by the Priority One leaders

AsthmaBlackoutsMigrainesMotion SicknessOther

Other (please specify):

YesNo

If Yes, please state the name of the condition, medication, dosage, side effects:

PenicillinOther (including any foods)

Other (please specify):

YesNo

YesNo

MEDICAL FORM MUST BE ACCEPTED BY CHILD’S PARENT OR GUARDIAN

I hereby authorise the leader in charge of Priority One or of the particular activity in which my child is involved to consent, where impracticable to communicate with me, to my child receiving such medical or surgical treatment as the leader may deem necessary at any time during Priority One programmes. I further authorise the use of Ambulance and/or anaesthetic by a qualified medical practitioner if in his/her judgement it is necessary. I accept responsibility for payment of all expenses associated with such treatment.

  • I understand that every effort will be made by the leader firstly to contact the above guardians in the event of any illness or accident.
  • I certify that the particulars given on this confidential medical report are complete and correct.