Data Capture Form

1Your details

2Child's details

3Emergency Contacts

4Health & Diet

5Photo consent

Who's filling in this form?*

First Last

Relationship*

Child's name*

First Last

Date of birth

DD slash MM slash YYYY

Year group*

Emergency Contact Information

Emergency Contact 1: Name*

First Last

Relationship*

Email*

Phone*

Notes

Emergency Contact 2: Name*

First Last

Relationship*

Email*

Phone*

Notes

Health and Diet

Immunisations*

Diphtheria

Tetanus

Polio

Whooping cough

MMR x 2

Meningitis C

None of the above

Please select all immunisations your child has had. If your child has not had one of these immunisations or completed the course (if relevant), please let the school office know if and when your child is immunised.

Immunisation Date: Diptheria

DD slash MM slash YYYY

Immunisation Date: Tetanus

DD slash MM slash YYYY

Immunisation Date: Polio

DD slash MM slash YYYY

Immunisation Date: Whooping Cough

DD slash MM slash YYYY

Immunisation Date: MMR (First dose)

DD slash MM slash YYYY

Immunisation Date: MMR (Second dose)

DD slash MM slash YYYY

Immunisation Date: Meningitis C

DD slash MM slash YYYY

Please tick if your child has had any of the following:*

None of the below

Mumps

Measles

German measles

Chicken pox

Whooping cough

Scarlet Fever

Does your child suffer from any of the following? If the answer to any of the below is Yes, please select and give full details below.*

None of the below

Asthma

Hay fever

Eczema

Allergies (food, bites, antibiotics, anti-histamine, suncream)

Epilepsy / fits / convulsions

Serious illness or operation

Diabetes

Details

Do you give consent for your child to be given prescribed medication by staff at Bassett House, eg: inhalers if required?*

Yes

Is your child allergic to plasters or antiseptic wipes?*

Yes

(Unless the school has been informed that your child is allergic to either plasters or antiseptics, if an accident should occur the wound will be cleaned with water and/or an antiseptic wipe and a plaster applied if necessary.)

Has your child been prescribed an epipen?*

Yes

Please note that the school requires two epipens for any child for whom an epipen has been prescribed – one to be kept in the school office and the other to be kept in the child’s classroom.

Please note below any current serious health conditions of which the school should be aware.

Does your child adhere to a specific diet for health or religious beliefs eg. vegetarian, vegan, halal, kosher etc?*

Yes

Does your child have any allergies, or medical or other needs in terms of their diet?*

Yes

If you answered yes, please give details below.

If so, please state them here. Any such dietary requirement must have been recommended by a medical doctor or be due to religion or belief (as protected by law).

Photo consent

I consent to my child being featured in photo and video content to be shared on the school's website, social media and in marketing materials for Bassett House and Dukes Education Group during my child's time at the school and for up to two years after leaving.*

I consent

I do not consent