LTO Autumn Sign-up and Medical Consent Form 13th-15th October 2017
Email address
Child's Name
Your answer
Date of Birth
MM
/
DD
/
YYYY
Instrument and standard
Your answer
Instrumental teacher
Your answer
School Attended
Your answer
Parent's Name (s)
Your answer
Home Address
Your answer
Home phone
Your answer
Mobile No.
Your answer
Alternative emergency contact - Name and relationship to child
Your answer
Alternative landline no.
Your answer
Alternative mobile
Your answer
G.P. Name and Address
Your answer
G.P. Phone No.
Your answer
Please indicate any medical needs and give details of child's symptoms, triggers, signs, treatments, facilities, equipment or devices, environmental issues etc.
Your answer
Please name any medication, dose, method of administration, when to be taken, side effects, contra-indications, administered by/self-adminstered with/without supervision
Your answer
Other Information
Your answer
The above information is, to the best of my knowledge, accurate at the time of writing and I give consent to LTO staff to carry out any necessary treatment in the case of an emergency.
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A copy of your responses will be emailed to the address you provided.
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