Medical and Support Information Form

The questions below are designed to allow us to understand any support that the young person
will need to take part safely in NCS.

We will use this information to make adjustments to NCS so we can provide a safe, positive and
meaningful experience for your young person.

Therefore, please provide as much detail as you can. We may contact you to follow up on this
further.

1.Is the young person's legal guardian

different from the person named in the ❏ No
original application? ​(Pull through name of ✘ Yes
❏
PG from account)

If "yes", please give details of the young person's legal guardian.

Name of legal guardian
What is the legal guardian's relationship to
the young person?
Telephone number of legal guardian
Email address of legal guardian
Address of legal guardian
Kamala Sri Valluripalli
Mother
07802665476
kamalasree@gmail.com
62, Catterick road, Bicester , OX26 1AW

2.Is the young person currently or have they

recently been in the care of a local authority? ✘ No
❏
(For example are they in foster care or in the ❏ Yes
care of a children's home)

If "yes", please give details of the young person's Social Worker or Key Worker.
Name of Social / Key Worker
Telephone of Social / Key Worker
Address of of Social / Key Worker
Email address of Social / Key Worker
Name of Local Authority
Who holds legal guardianship and can
consent to the young person going on NCS?
What are the care arrangements for the ❏ Cared for by family member
young person? Please select all that apply. ❏ Children's Home
❏ Foster placement
❏ Respite care
❏ Semi-independent living / Leaving Care
❏ Unaccompanied minor
 .Does the young person have any of the following
allergies? (Please select all that apply)
❏
✘ None
❏ Dairy
❏ Eggs
❏ Fish or shellfish
❏ Latex
❏ Medicines (please specify): ____________________________________________
❏ Nuts
❏ Other (please specify): ________________________________________________
How severe is the allergy? ❏ Mild
❏ Moderate
Please see below some guidance for the ❏ Severe
severity of the allergy and pick the most
appropriate:

Mild ​- The young person may feel sick, get a rash or experience a tight throat
Moderate ​- The young person is sick, gets a severe rash or experiences swelling
Severe ​- They are at risk of anaphylactic shock, have difficulty breathing or are severely
impacted
When does the reaction happen? (​Please tick ❏ When eaten
all that apply) ❏ When touching traces of the allergic item
❏ Airborne particles / when the allergic
item is in the environment
Please describe a typical reaction to each
allergy

4.Does the young person have an EpiPen

or similar device for treating anaphylaxis?
✘ No
❏
Please be aware that in an emergency, our
❏ Yes
staff may need to administer your child's
treatment for anaphylaxis. (By law they are
able to do this).

.Does the young person have any dietary requirements?

Please select all that apply. We will do everything we can to cater for specific requirements and
provide a suitable option for you.

✘ None
❏ ❏ No eggs
❏ Gluten free diet ❏ No pork
❏ Halal ❏ Vegan
 ❏ Kosher ❏ Vegetarian
❏ No beef ❏ Other (please specify):
_____________________________

.Does the young person have any religious

or cultural requirements? Please select all ❏ None
that apply. ❏ Observing Ramadan
❏ Prayer space required
We will do everything we can to cater for ❏ Other (please specify):
specific requirements and make adjustments __________________________
for you.

.Does the young person have any of the following?​ Please select all that apply.

✘ None
❏

❏ A severe head injury ❏ Infectious disease

❏ Anaemia ❏ Migraines
❏ Asthma ❏ Seizures
❏ Blackouts ❏ Sickle cell anaemia
❏ Bladder or urinary condition ❏ Sickle cell trait
❏ Blood disorder ❏ Skin condition
❏ Cystic fibrosis ❏ Stomach, bowel or abdominal condition
❏ Epilepsy ❏ Treatment for a non-minor complaint in
❏ Fainting attacks the last two years
❏ Heart condition ❏ Any other injuries
❏ Any other lung condition

If you have selected any of the above;

Are any of these conditions ongoing? ❏ No - fully recovered
❏ Yes - ongoing with no daily impact
❏ Yes - ongoing with minor daily impact
❏ Yes - ongoing with major daily impact

For sickle cell trait and sickle cell anaemia ​only

Has the young person ever had a sickle cell ❏ No

crisis? ❏ Yes

For Epilepsy ​only

Does the young person carry Epilepsy ❏ None

rescue medication for extended seizures? ❏ Buccal midazolam
(Please select all that apply) ❏ Rectal diazepam
 ✘ No
❏
.Does the young person have diabetes?
❏ Yes - Type 1
❏ Yes - Type 2

If you have selected “Yes”, please answer the following questions.

Does the young person manage this condition ❏ Yes

themselves? ❏ No
Does the young person carry emergency ❏ Yes
medication for their diabetes? ❏ No
Does the young person need a fridge to store ❏ Yes
their medication in? ❏ No

When answering the following questions please be aware of the following:

● On NCS our standard staff ratio is one staff member for every 14 young people.
● NCS includes classroom based activities, physical activities and staying away from home
residentially.

❏ No
.Does the young person have a sight
impairment which means they may need extra ✘ No - Wears glasses/contact lenses and
❏
support on NCS? vision is fully corrected
❏ Yes - Sight impaired
❏ Yes - Severely sight impaired

If ​yes ​to the above question, please provide as much detail as possible, including what support
may be required during NCS:

❏
✘ No
1 .Does the young person have a hearing
impairment which means they may need extra ❏ Yes - Mild
support on NCS? ❏ Yes - Moderate
❏ Yes - Severe
❏ Yes - Profound

If ​yes ​to the above question, please provide as much detail as possible, including what support
may be required during NCS:
11.Does the young person have a physical
disability which means they may need extra
support on NCS?
✘ No
❏
❏ Yes and is a wheelchair user
❏ Yes and uses a wheelchair some of the
time
❏ Yes and needs some mobility support
❏ Yes but does not use a wheelchair or
require additional support

If ​yes ​to the above question, please provide as much detail as possible, including what support
may be required during NCS:

12.Does the young person have any of the

following? Please select all that apply.

✘ None
❏

❏ ADD
❏ ADHD ❏ Dyslexia
❏ Asperger's syndrome ❏ Dyspraxia
❏ Autism ❏ Hyperactivity
❏ Developmental delay ❏ Other learning difficulties
❏ Down's syndrome ❏ Speech and language difficulties

If you have selected any of the above, please answer the following questions.

Does the young person need any support ❏ Yes

with this during NCS? ❏ No

Please provide as much detail as possible, including what support may be required during NCS;

1 .Does the young person have any of the following mental health needs or

behaviours? Please select all that apply.

✘ None
❏

❏ Anxiety ❏ Panic attacks

❏ Depression ❏ Post-traumatic stress disorder (PTSD)
❏ Eating disorder ❏ Psychosis
 ❏ Hallucinations (visual or hearing voices) ❏ Substance misuse
❏ Obsessive Compulsive Disorder (OCD) ❏ Self harm
❏ Other

If you have selected any of the above, please answer the following questions.

How recently has this affected the young
person's mental health?
Does the young person currently see a
professional or specialist for this?
❏ Ongoing - this is currently affecting the
young person
❏ Recent - This has affected the young
person in the last year
❏ Not current - This affected the young
person more than a year ago
❏ Yes
❏ No

Please provide as much detail as possible, including what support may be required during NCS
and what current professional support the young person receives;

14.Does the young person take or

carry medication prescribed by a ✘ No
❏
doctor or pharmacist to help manage ❏ Yes
an existing condition?

If you have selected “Yes”, please answer the following questions.

What is the name and dosage of this

medication? Is this prescribed by a doctor or
over-the-counter medication?
What is the medication for?
Can the young person independently store
❏ Yes
and take all of these medications
❏ No
themselves?

✘ Speaks fluent English

❏
1 .How well does the young person speak and
❏ Speaks and understands English to a
understand English?
good level
❏ Speaks and understands English to a
basic level
❏ Does not speak English

If the young person does not speak English, what support is currently in place or needed? ​(For
example, does the young person use British Sign Language, Makaton, PECs or have other
classroom support).
1 .Does the young person receive any additional support at school or in an educational
setting? (Please select all that apply)

❏ No extra support
❏ Occasional Support - Supported by staff only when needed
❏ 1:1 staff member for young person - For literacy and numeracy support
❏ 1:1 staff member for young person - For behavioural support or following instructions
❏ Other (please specify): ________________________________________________

1 .Does the young person have a Statement ✘ No

❏
of Special Educational Needs (SEN) or an
❏ Yes
Education, Health & Care (EHC) plan?

If “Yes”, what is this for?

1 .Is the young person known to Youth

Offending Team/Youth Offending Services/ ✘ No
❏
Probation Services or have any criminal
❏ Yes
convictions, ongoing police investigations or
pending criminal charges?

Please provide as much detail as possible, including what support may be required during
NCS.

If the young person is known to Youth Offending Team (YOT), please provide their details.

Name of YOT Worker

Telephone of YOT Worker
Email address of YOT Worker
Name of YOT service

✘ Yes
❏
1 .Can the young person swim?
❏ No

✘ No / does not apply

❏
2 .Is the young person pregnant?
❏ Yes
 ✘ Yes
❏
21.Is the young person's tetanus injection
up to date? ❏ No
❏ Unsure

❏ Female
22.What is the young person's gender?
❏
✘ Male
❏ Non-binary/ third gender
❏ Prefer to
self-describe:_____________________
❏ Prefer not to say

Transgender is an umbrella term that refers to people whose gender identity, expression or
behavior is different from those typically associated with their assigned sex at birth. Other
identities considered to fall under this umbrella can include non-binary, gender fluid, and
genderqueer – as well as many more.
Does the young person identify as ✘ No
❏
transgender? ❏ Yes
❏ Prefer not to say

2 .Does the young person have caring ✘ No

❏
responsibilities for a relative or child? ❏ Yes

If “yes”, please provide as much detail as possible, including what support may be required
during NCS.

24.Is there anything else we need to be aware ✘ No

❏
of to support the young person on NCS safely? ❏ Yes

If “yes”, please provide as much detail as possible, including what support may be required
during NCS.

The following questions are used to check that we are providing NCS to different groups of
young people

2 .Has the young person ever received ❏ Yes

Free School Meals? ✘ No
❏
2 .What is the young person's ethnic background?

❏ Arab ❏ Other Mixed background

❏ Bangladeshi ❏ Other White background
❏ Black African ❏ Pakistani
❏ Black Caribbean ❏ Traveller of Irish heritage
❏ Chinese ❏ White and Asian
❏ Gypsy or Roma ❏ White and Black African
❏
✘ Indian ❏ White and Black Caribbean
❏ Irish ❏ White British
❏ Other Asian background ❏ Any other ethnic group
❏ Other Black background ❏ Prefer not to say

2 .What is the young person's faith or religion?

❏ Muslim
❏ Buddhist
❏ Sikh
❏ Christian
❏ None
❏
✘ Hindu
❏ Other
❏ Jewish
❏ Prefer not to say

The following questions provide us information about who we should contact in case of an
emergency.

Please give details of the young person's GP.

GP Name Montegamory Surgery

GP address and postcode Ox266ht

GP phone number 01869249222

Emergency contact - Primary contact

Name Kamala Sri

Relationship to young person Mother

Telephone - Home

Telephone - Mobile 07802665476

Telephone - Work
 Address: Ox 26 1aw

Secondary contact if Primary unavailable

Name

Relationship to young person

Telephone - Home

Telephone - Mobile

Telephone - Work

Do you consent to your young person going on a programme?

✘ Please select this box if you consent

Any changes to the above information should be communicated to NCS so that we  can update
our records accordingly prior to the Young Person starting their NCS  Programme.

Kamala Sri Valluripalli

Mar 14, 2019

TC Medical Form
Final Audit Report 2019-03-14

Created: 2019-03-06

By: NCS Team (adobe_ngen@ncstrust.co.uk)

Status: Signed

Transaction ID: CBJCHBCAABAA-0KyWVyDIZWKN3lUV_lpNEBKwk18A7H7

"TC Medical Form" History

Document created by NCS Team (adobe_ngen@ncstrust.co.uk)
2019-03-06 - 14:51:14 GMT- IP address: 85.222.138.8

Document emailed to Kamala Sri Valluripalli (kamalasree@gmail.com) for signature

2019-03-06 - 14:51:19 GMT

Document viewed by Kamala Sri Valluripalli (kamalasree@gmail.com)

2019-03-06 - 14:53:43 GMT- IP address: 82.132.241.45

Document viewed by Kamala Sri Valluripalli (kamalasree@gmail.com)

2019-03-13 - 15:02:49 GMT- IP address: 82.132.220.189

Document e-signed by Kamala Sri Valluripalli (kamalasree@gmail.com)

Signature Date: 2019-03-14 - 06:45:33 GMT - Time Source: server- IP address: 151.225.23.251

Signed document emailed to all eligible parties.

2019-03-14 - 06:45:33 GMT