CMSI 5 Day | UK Film School

Please note that the deadline for receipt of all student information forms and balance of payment is six weeks prior to the course.

First name *

Last name *

Date of birth *

Age at time of course *

To ensure that a parent/guardian may be contacted if necessary - please complete the following:

Home Contact

Contact name *

Relationship to student *

Mobile number *

Work telephone

Address *

Alternative Contact

Contact name *

Relationship to student *

Mobile number *

Work telephone

Address *

Does the student have any condition requiring medical treatment? If yes, please give further information. *

Does the student suffer from any allergies to foods, plants, animals, medication, etc or any phobias? If yes, please give further information. *

Does the student take any form of medication/use inhalers? If yes, please give further information. *

If medication cannot be self-administered by the student for any reason, do you consent to a member of staff administering the medication? *YESNO

To the best of your knowledge, has the student been in contact with any contagious or infectious diseases within the last 6 months or suffered from anything that may be or become contagious or infectious? If yes, please give further information. *

Has the student had Covid 19 or have been in contact with someone who has Covid 19 within the last 14 days. Please do not attend Film School if the student is currently testing positive for Covid 19 or are suffering any symptoms of Covid 19 e.g. high temperature, a new continuing cough, sore throat, aching body. *YESNO

Are there any activities that the student may not participate in for health reasons? *YESNO

Is the students tetanus vaccination up to date? *YESNO

Please give details of any other illnesses that the student suffers from which may impact on their ability to take part in any activities associated with the residential. *

Are there any activities that the student may not participate in for health reasons? If yes, please give further information. *

Please specify any medical treatment for which consent is withheld. *

Please indicate if the student can swim 50 metres of more *YESNO

Please indicate if the student is water confident *YESNO

Is there any other information relating to the students health and safety that we ought to be aware of (e.g. sleep walking, behavioural)? *YESNO

Doctor Information

Doctor name

Doctor telephone number

Doctor address

Undertaking

I undertake to inform UK Film School as soon as possible of any changes in the medical circumstances of the student between the date of this form and the commencement of the visit.

Declaration

I agree to the student receiving emergency medical, dental or surgical treatment, including anaesthesia and/ or a blood transfusion as considered necessary by the medical authorities present. I also understand that the school may exercise its discretion to refuse to accept a student unless it receives a completed and signed form.

Parent/guardian agreement - I accept the terms above *

YES

Relationship to student *

5 Day Summer Film School

UK Film School Medical Consent Form

Home Contact

Alternative Contact

Doctor Information

Undertaking

Declaration

Parent/guardian agreement - I accept the terms above *

In partnership with

Summer School Forms & Information

@ukfilmschool