GM Medical, emergency, and consent form

Gwent Music medical and consent form

Member’s details

Full name *

Date of Birth *

Emergency contacts

Emergency contact 1: Name *

Emergency contact 1: Number *

Emergency contact 2: Name *

Emergency contact 2: Number *

Medical information

Medical facts or allergies *

Are you aware of any medical facts or food allergies (including any allergy to a particular drug) concerning your child, which you think should be brought to the attention of Gwent Music staff?

Medication/drugs

Please provide particulars of any medication/drugs which your child regularly takes or carries.

GP contact details

Please provide the name, address & contact number for your child’s GP.

If you are human, leave this field blank.