Expressions Academy: Medical Form

Medical Form

It is a legal requirement to fill in the medical form below to the best of your knowledge.
Please ensure that you have completed the Application Form first.

Please fill out all the relevant fields below

Name *
Email *
Please describe a full record for broken Bones, joints or Spinal injuries with dates and record of treatment:
Have you has any Serious diseases, blood disorders or heart conditions E.G. polio, glandular fever, diabetes:
Do you have any allergies, hay fever or skin conditions:
Ear/Eye problems:
Please describe any Serious Operations that you have had:
Do you suffer from migraines: *
No Yes
Do you have any Disabilities E.G. Dyslexia:
Doctors Name: *
Doctors Address: *

Signatures

Signature of Applicant: *Ticking this box substitutes as a legal binding signature.
I declare that, to the best of my knowledge, the information given in this medical form is correct and complete
Guardians Signature:
(If applicant is under 18) - I, the Parent or Guardian, approve and give my consent to this application:
Guardians Name:

Verification

Please enter any two digits with no spaces (Example: 12) *
This box is for spam protection - please leave it blank: