GAP Health Questionnaire This form will supply us with the student's relevant medical information. All applicants or parents where appropriate must fully complete and submit a health questionnaire, which will be passed onto the college pastoral team. Please be thorough, open and honest and notify us of all health or learning concerns, to enable the necessary support to be provided. We cannot be held responsible for issues that arise out of a non-disclosure.Name of student*Course dates*Name of person filling out this form*Relationship to student* Medical Information and Consent In order to ensure the student’s wellbeing it is important that this form is completed to the best of your ability and knowledge. 1. Does the student have any of the following? Physical disabilities Learning disabilities or difficulties Special requirements or needs If you have checked one of the above, please give details here.2. Does the student have allergies to any of the following? Food Animals Medicine If you have checked one of the above, please give details here.3. Detailed Information Is the student taking any medication? Does the student have any special medical needs? Does the student have any special dietary requirements? Does the student have any eating disorders? If you have checked one of the above, please give details here.4. Does the student have any of the following? Asthma Epilepsy Diabetes Mental health issues If you have checked one of the above, please give details here.5. In case of illness or injury to the child, as the legal guardian, I hereby grant permission to Campus Oxford & its agents to authorise any medical treatment advised by the attending medical consultant and I undertake to pay for any such treatment not covered by insurance.* Yes No Please supply a phone number for emergencies.