PLYMOUTH LEANDER SA by s1r0E821

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									                                           CONFIDENTIAL
                                       Guardianship Services UK
                               EMERGENCY CONTACTS
                  HEALTH QUESTIONNAIRE AND CONSENT INFORMATION


FULL NAME ( Student) : ___________________________________________________________


DOB: DD _ _ / MM _ _ / YYYY _ _ _ _


ADDRESS ( UK) :_________________________________________________________________


MOBILE in UK (Student) :___________________
++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

DOCTOR’S NAME (UK) :________________________________________


ADDRESS:___________________________________________ Post Code__________________


Tel No: _________________________________
++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

Name - NEXT OF KIN ( NOK) : 1,_______________________2,_____________________________


EMERGENCY CONTACT (NOK): 1,_______________________2,_____________________________


Emergency - E mail address:     1,_________________________2,___________________________

MEDICAL CONDITIONS                   YES/NO                             DETAILS/MEDICATION

DIABETES


ASTHMA


EPILEPSY


ALLERGIES/DIET


ANY OTHER SIGNIFICANT INFO


I consent to my child receiving emergency medical treatment, which might involve the use of
anesthetics and blood transfusions.


SIGNED…………………………………………………………………………DATE………………………………………….

PRINT NAME……………………………………………………RELATIONSHIP……………………………………….




         Return to: Guardianship Services UK, Lamerton House, 67, Hermitage Road, Plymouth. PL3 4RX
                   E Mail: info@guardianship-services-uk.com    Tel: + 44 (0) 771 404 7163

								
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