International Summer School: Medical Form

Step 1 of 7 - Statement of previous health

CONSENT TO OPERATION TO BE COMPLETED FOR ALL PUPILS
Should your child need surgery, we will make every effort to get in touch with you beforehand. If your child is aged 16, they can consent to treatment themselves, however there may be occasions (for example, acute Appendicitis) where time is of the essence and for those cases, we would be grateful if you could sign the consent form below.
I, name of Parent or Legal Guardian(Required)
First Last
of permanent address:(Required)
Street Address Address Line 2 City County / State / Region ZIP / Postal Code
Full Name of Pupil(Required)
First Last
Give consent to undergo any operation which may be deemed necessary during periods of residence at Sedbergh School and for the administration of a general or local anesthetic for that purpose.(Required)
- I give my consent
- I DO NOT give my consent:
Signature
Today's Date(Required)
DD slash MM slash YYYY

CONSENT TO MEDICATION FOR ALL PUPILS
Guidelines are issued to the House Staff regarding the dispensing of over-the-counter remedies, such as paracetamol and antihistamines. If you are happy for your child to receive these treatments, please sign below and/or record any specific objections:
I, name of Parent or Legal Guardian(Required)
First Last
of permanent address:(Required)
Street Address Address Line 2 City County / State / Region ZIP / Postal Code
Full Name of Pupil(Required)
First Last
*If you do not consent please note that this would mean your child would not be given paracetamol or antihistamines if required. However, if your child is 16-years old or over, they can self-consent.(Required)
- I give my consent
- I DO NOT give my consent:
Signature
Today's Date(Required)
DD slash MM slash YYYY

CONSENT TO PRIVATE NON-NHS INFLUENZA VACCINATION FOR ALL PUPILS
Please note: Pupils in reception to year 6 and pupils considered to be at risk will receive a free NHS nasal flu vaccine. Separate consent forms will be sent for that. All other pupils will be offered annual influenza vaccination injection for a small charge. Please submit this consent if you wish your child to receive that. Pupils over the age of 16 years of age can self-consent.
I, name of Parent or Legal Guardian(Required)
First Last
of permanent address:(Required)
Street Address Address Line 2 City County / State / Region ZIP / Postal Code
Full Name of Pupil(Required)
First Last
Hereby give/do not give consent for influenza vaccingation. Note that if your child is 16-years old or over, they can self-consent.(Required)
- I give my consent
- I DO NOT give my consent:
Signature
Today's Date(Required)
DD slash MM slash YYYY

CONSENT FOR SUMMARY CARE RECORD
TO BE COMPLETED FOR ALL PUPILS AGED 16 & OVER
I, name of parent or legal guardian(Required)
First Last
hereby give consent for my son/daughter/ward
Full Name of Pupil(Required)
First Last
Summary Care Record
- Express consent to medication, allergies and adverse reactions only
- Express dissent (opted out) Patient does not want a Summary Care Record
Local Shared Record
- Patient consents to sharing the detailed record
- Patient does not wish to share the detailed record
Pupil Signature
Today's Date(Required)
DD slash MM slash YYYY
Summary Care Record:

A Summary Care Record is automatically created for children up to the age of 15 years and 9 months, as their consent is not required. If a child’s parent/legal guardian does not wish the child to have a summary care record they must discuss this with their child’s GP, but ultimately it is the GP’s decision, because of their duty of care to the child. The Summary Care Record is meant to help emergency doctors and nurses help you when you contact them when the surgery is closed. Initially, it will contain just your medications and allergies.

As the central NHS computer system develops, (known as the ‘Summary Care Record’ - SCR), other staff who work in the NHS will be able to access it along with information from hospitals, out of hours services, and specialists’ letters that may be added as well.

Your information will be extracted from practices such as ours and held on central NHS databases.

Local Shared Record:

Health Services in South Lakeland now have the ability to share some information from your medical records with other health services that provide you with care. This information is limited, is called a local shared record and is not linked to the national system, (Summary Care Record). It does not copy details and file them in a national database, rather making a view available if needed with your consent at some point in the future.

Only healthcare professionals directly involved with your care can see your shared record and only at the time they are treating you. This may include Cumbria health oncall (CHOC), Accident and Emergency departments, community nurses and physiotherapists.
Consent(Required)
UK GENERAL DATA PROTECTION REGULATIONS

Our Privacy Notices regarding the collection, safekeeping and use of your data can be found on our website (Privacy Policy - Sedbergh School http://sedberghschool.org/privacy-policy) or by request from The Bursar (Compliance), Sedbergh School, Malim Lodge, Sedbergh LA10 5RY. (tr@sedberghschool.org) If you have any concerns about the data we hold or do not wish to receive any further communications from us, don't hesitate to contact The Bursar (Compliance).
I agree to the privacy policy.

Quick Links

International Summer School: Medical Form

Step 1 of 7 - Statement of previous health

STATEMENT OF PREVIOUS HEALTH

PARENT/LEGAL GUARDIAN DETAILS

PARENTAL RESPONSIBILITY

Ongoing Medical Problems

CONSENT TO OPERATION TO BE COMPLETED FOR ALL PUPILS

CONSENT TO MEDICATION FOR ALL PUPILS

CONSENT TO PRIVATE NON-NHS INFLUENZA VACCINATION FOR ALL PUPILS

IMMUNISATION RECORD THIS MUST BE COMPLETED WITH FULL DETAILS FOR ALL PUPILS

CONSENT FOR SUMMARY CARE RECORD

IMMUNISATION	DATES GIVEN

IMMUNISATION	DATES GIVEN

IMMUNISATION	DATES GIVEN

IMMUNISATION	DATES GIVEN