MEDICAL REPORT
Name of Child
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Nationality
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Birth date
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Height
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Weight
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Doctors Name and Address
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Doctors Telephone
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Private Medical Insurance Yes [ ] No [ ]
Vaccinations
Against .......................................................... Date .....................
Against ...........................................................Date .....................
Against .......................................................... Date .....................
Against ...........................................................Date .....................
Blood Group
.............................................................................
Is the child on regular medication, please details and dosage
...................................................................................................................................
..................................................................................................................................
Any health problems ................................................ Or Diet ....................................
Does your child suffer from any allergies (medical or food)?.....................................
..................................................................................................................................
Does your child wear glasses? Yes [ ] No [ ]
Can your child partake safely in all sports? Yes [ ] No [ ]
Father's Contact details
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Mother's Contact details
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Details of another contact in case of emergency if you are unobtainable
(i.e. Grandparent, family member, or family friend)
....................................................................................................................................
Father's signature
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Mother's signature
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