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Medical Form

Order No.(Required)

Name of School/Group(Required)

First

Date(Required)

MM slash DD slash YYYY

Group Leader(Required)

First

Please complete the form below and tell us any information which you may feel to be relevant. Please also advise children’s first name on the form and identify them to their guide at the start of the tour.

Are there any children that may suffer from adverse reactions to our scenarios?(Required)

Yes

For example, experience of distress from fire, accident or a long term illness or bereavement of a close family member.

If yes, please provide details including an approximate date where appropriate.

Are there any children that have an educational special needs or children that have 1:1 support at school?(Required)

Yes

For example, Autism, ADHD etc.

If yes, please specify the type(Required)

Autism

Aspergers

Behavioural

ADHD

Hearing Impairment

Visual Impairment (Please indicate if you wish us to keep the warehouse lights on for this tour.)

Other (Including EAL)

Mobility Issues (Are they able to walk up a flight of stairs?)

Please provide details where applicable

Are there any children that have health issues?(Required)

Yes

For example, Epilepsy, Asthma etc.

If yes, please specify the type(Required)

Epilepsy (Please advise if they are affected by strobe lighting)

Allergies

Asthma

Diabetes

Other

Please provide details where applicable

Any other comments?

Safety Centre Ltd

18 Carters Lane
Kiln Farm
Milton Keynes
MK11 3ES

01908 263009
info@safetycentre.co.uk

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Safety Centre is both a Registered Charity and a Limited Company. Company Registered Number: 2709081. Registered Charity Number: 1019093. Managed by GIANT.