Taster Day Pupil Information

Child's Details
Child's First Name(s):*
Child's Last Name:*
Child's Date of Birth:*

Day
Month
Year
Date of Taster Day

Day
Month
Year

Consent for Routine Medical Treatment
Under current legislation, it is necessary for parents to give consent to their son/daughter receiving simple routine medical treatment in school.
For example:

- Bumps and Bruises: a cold pack and if necessary cream e.g. Arnica
- Cuts and Grazes: a medicated wipe and if necessary antiseptic cream/spray and plaster
- Head/ear ache, temperature, coughs and sore throats: a Paracetamol or Ibuprofen tablet/suspension
- Insect Bites and Stings: anti-histamine cream or cold pack
- Allergic Reactions: anti-allergy syrup
- Strong Sunlight: apply sun cream to your child's face, neck, arms and legs.
Please indicate your consent for your child to receive simple medical treatment at school.*

Yes

No

General Medical Information
Please notify us of any medical information of which we should be aware, including any special dietary requirements. Any details supplied will be held securely in the School's Management Information System.
Child's NHS Number:*

Date of Last Tetanus Injection:*

An estimated date is sufficient
Has child received all childhood immunisations:*

Yes

No
Which childhood immunisations has your child NOT received:*
Any medical conditions:*

Yes

No
Please give full details of any medical conditions:*
Does your child have any non-dietary allergies:*

Yes

No
Please give details of non-dietary allergies:*
Please give details of your Family Doctor, and any other medical professionals your child regularly sees:*
Please include name of GP surgery, telephone number and postcode.

Dietary Requirements
Please note, whilst we can provide meals which do not include nominated allergens, we cannot guarantee that dishes do not contain traces of allergens, as they will be stored and prepared in the same areas as nominated allergens. There is a risk of cross contamination on display counters, particularly self-service areas such as salad bars and dessert counters.

Please be aware that while our catering provider, Holroyd Howe, do not use nuts in any of the food we prepare and serve, we are unable to guarantee that dishes/products served are totally free from nuts/nut derivatives, due to the use of precautionary allergy statements such as ‘may contain’ used by our suppliers.
Does child have any special dietary requirements:*

Yes

No
Please detail of any food groups not permitted due to religious faiths, beliefs or preferences:
Please identify any/all of the allergens/food groups your child must avoid:
Tick all that apply
Peanuts
Nuts
Eggs
Milk
Sesame Seeds
Molluscs
Crustaceans
Celery
Gluten
Soy Beans
Mustard
Sulphite
Fish
Lupin
Other
Please provide further details of the nature of the allergy/intolerance/exclusion:*
Has this allergy/intolerance been medically diagnosed:*

Yes

No
Please give your permission to share the above information and a photo of your child to Holroyd Howe:*
This is necessary to enable Holroyd Howe to assist Pennthorpe in correct food provision

Yes
Please give your permission for child's photo to be displayed in the main serving area:*
This is necessary to enable catering staff to check information easily

Yes
Holroyd Howe use a colour coding system to identify special diets. Please tick which applies to your child:*

RED - Child has a severe life-threatening allergy e.g. anaphylactic shock

AMBER - Child has an allergy or intolerance

BLUE - Child excludes foods due to preference, including religious preference
If you tick RED we strongly recommend that a freshly prepared pre-plated meal is provided for your child. A pre-plated meal is the safest way to minimise the risk to the pupil.
Please complete the disclaimer:
Parents of children with a severe life-threatening allergy (e.g. anaphylactic shock) are advised that their child receive a pre-plated meal at Pennthorpe.

If you DO NOT want your child to receive a pre-plated meal you must agree with the following statements:

- I confirm I do not want my child to receive a pre-plated meal.
- I am aware that Holroyd Howe are unable to guarantee that dishes/products served are totally free from nuts/nut derivatives, due to the use of precautionary allergy statements such as ‘may contain’ used by our suppliers.
- I am aware that the meals provided to my child will be prepared in the same areas as nominated allergens.
- I am aware there is a risk of cross-contamination on display counters, particularly at self-service areas such as salad bars and dessert counters.

I am happy for my child to have a pre-plated meal.

I DO NOT wish for my child to have a pre-plated meal, and I have read and understood the above statements.
Name
This field is for validation purposes and should be left unchanged.

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Pupil Information

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Child's Details

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Parental Contacts

Additional Contacts

Consent for Routine Medical Treatment

General Medical Information

Dietary Requirements

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