EMERGENCY INFORMATION RECORD FOR ALL PUPILS

The data submitted will be part of the school’s record system to be used if needed in an emergency.

If you prefer to print out and fill in the form, click here to download it, and once filled in, please hand it into the school office.

Please fill in ONCE PER CHILD.
If you have more than one child, immediately after submitting the first, it will allow you to add another (with pre-filled data).

1) Child Information

*Forename
*Surname
*Date of Birth (DD/MM/YYYY)
 

2) Parent/Carer Information

If applicable, please fill in both adults information. (minimum requirements adult 1 OR adult 2)
CHECK HERE IF ADULT 1 LIVES WITH ADULT 2: (this will automatically fill in most of Adult 2's information)
ADULT 1 Female MOTHER/CARER
*Forename
*Surname
*Address
Address 2
*Town/City
*Postcode
*Tel HOME Number
Tel WORK Number
*Mobile Number
If works, please details of days/times.
ADULT 2 Male FATHER/CARER
*Forename
*Surname
*Address
Address 2
*Town/City
*Postcode
*Tel HOME Number
Tel WORK Number
*Mobile Number
If works, please details of days/times.

3) Phone Numbers - Order of Importance

Please put the following details in order of contact. These numbers will be called in the order below.
  *Relationship to child *Full Name *Contact Number Alternative Number
*CONTACT 1
*CONTACT 2
*CONTACT 3

4) Doctor & Surgery Information

*Doctor Name
*Address
Address 2
*Town/City
*Postcode
*Contact Number

5) Medical Details

- Please ensure that only up-to-date and current medication is kept in school.
- Please ensure that medication required for your child is handed personally to someone in the medical room and an 'Agreement for school to administer medicine' form is completed and signed, together with handwritten letter giving the school authorisation to give medicine. Please do not leave medicines in the medical room unattended.
Any known allergies:
Medication Needed (EG: Inhalers/EPI-Pens):
Any other important medical information:

6) Confirmation