AXA

School details

This application is for Halliford School

Russell Road
Shepperton on Thames
Middlesex
TW17 9HX

01 Is the above school detail correct? *

Only answer if you've selected 'No' for field-01

If your child's school details are incorrect, please contact the school directly. You can find details in your school information pack.

Only answer if you've selected 'Yes' for field-01

Child details

02 Your child's first name *

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03 Your child's last name *

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04 Your child's sex at birth *

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05 Your child's date of birth *

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05-1 Your child's join date *

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05-2 You have entered an enrolment date of [DATE] . Please confirm this is correct. *

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Parent / Legal Guardian details

Please note that only your child is covered under the AXA Health Pupils' Healthcare Scheme - Parents and Legal Guardians are not covered.

06 Parent / Legal Guardian's first name *

07 Parent / Legal Guardian's last name *

08 Other Parent / Legal Guardian's first name

09 Other Parent / Legal Guardian's last name

Only answer if you've selected 'Yes' for field-01

10 Address line 1 *

11 Address line 2 *

12 Address line 3 *

13 Address line 4

14 Post code / ZIP code *

15 Telephone number(s) *

15-1 Additional phone number

16 Email address *

Please provide a memorable date that we can use to identify you when you call.

17 Your memorable date *

Please provide a hint/reminder that we can use to prompt you when you call, if you need help remembering your memorable date provided above - e.g. your birthday or wedding day.

18 Your memorable date hint / reminder *

Only answer if you've selected 'Yes' for field-01

Appointment of an Appointed Guardian

Appointing someone else to manage your child's claims (Appointed Guardian)

How can I appoint an Appointed Guardian?

If your child is under 16

You can appoint Appointed Guardian/s to manage their claim/s by providing their details in this form. You and other Parents/Legal Guardians will still be able to manage your child's claims.

If your child is over 16

You'll need their consent before appointing Appointed Guardian/s to manage their claims. Even Parents/Legal Guardians need to be appointed in this form to manage claims on behalf of their child if the child is over 16.

Who can be an Appointed Guardian?

Appointed Guardian/s could be the school, or someone else or both - e.g. it could be you and another Parent if your child is over 16 (if your child is under 16, you don't need to be formally appointed), another relative or family friend. Appointed Guardians must be over 21 years old.

What can an Appointed Guardian do?

Details of what an Appointed Guardian can do are provided below. Importantly, only Parents and Legal Guardians are ever able to cancel or amend your child's cover.

Where does correspondence about the AXA Health Pupils' Healthcare Scheme go?

All correspondence will be addressed to the child, care of the school (for example, Child Name, c/o Sample School, Sample Town, UK, A1 2BC).

Your child will be responsible for passing it to you or any other Parent, Legal Guardian or Appointed Guardian.

If you and your child would like to amend your Appointed Guardian choices in the future, please contact us on pupilshealth@thephc.co.uk and we will be happy to assist you.

19-00 Please tick to confirm that you have read and accept the information above. *

Only answer if you've selected 'Yes' for field-01

19-01 Is your child 16 or over? *

Only answer if you've selected 'Yes' for field-01

19-02 Do you wish to appoint the Parent / Legal Guardian named above as an Appointed Guardian? *

Only answer if you've selected 'Yes' for field-19-01

19 Do you wish to appoint Halliford School as an Appointed Guardian? *

19-1 Do you wish to appoint someone else as an Appointed Guardian? *

19-2 I am not appointing any Appointed Guardian/s. I understand that I am responsible for managing any claim/s for my child and that AXA Health will send all correspondence to the school, who will forward it to my child to act upon as required. *

Only answer if you've selected 'No' for field-19-01

AND

If you've selected 'No' for field-19

OR

If you've selected 'No' for field-19-1

19-4 My child has chosen to manage their claim/s themselves. *

Only answer if you've selected 'Yes' for field-19-01

AND

Only answer if you've selected 'Yes' for field-19-02

AND

If you've selected 'Yes' for field-19

AND

If you've selected 'No' for field-19-1

19-5 I confirm that my child has consented to the Appointed Guardian/s appointed in this form. *

Only answer if you've selected 'Yes' for field-19-01

AND

Only answer if you've selected 'Yes' for field-19-02

OR

If you've selected 'Yes' for field-19

OR

If you've selected 'Yes' for field-19-1

19-6 My child/I understand that AXA Health will share medical information with the Appointed Guardian/s to manage any claims/s for my child. *

Only answer if you've selected 'Yes' for field-19-02

OR

Only answer if you've selected 'Yes' for field-19

OR

Only answer if you've selected 'Yes' for field-19-1

19-7 My child/I would like the Appointed Guardian/s to be able to authorise AXA Heath to share my child's personal information, including their medical information, with third parties so that they can access services that are part of their membership. If AXA Heath needs to share your child's information for this purpose, we'll ask the Appointed Guardian dealing with the relevant claim to authorise this at the time. Details of these third-party services can be found in the policy handbook and axahealth.co.uk/pupilshealthscheme. *

Only answer if you've selected 'Yes' for field-19-02

OR

Only answer if you've selected 'Yes' for field-19

OR

Only answer if you've selected 'Yes' for field-19-1

19-1-1 Appointed Guardian's first name *

Only answer if you've selected 'Yes' for field-19-1

19-1-2 Appointed Guardian's last name *

Only answer if you've selected 'Yes' for field-19-1

19-1-3 Telephone number(s) *

Only answer if you've selected 'Yes' for field-19-1

19-1-4 Relationship to child *

Only answer if you've selected 'Yes' for field-19-1

19-1-5 Email address *

Only answer if you've selected 'Yes' for field-19-1

19-1-6 Address line 1 *

Only answer if you've selected 'Yes' for field-19-1

19-1-7 Address line 2 *

Only answer if you've selected 'Yes' for field-19-1

19-1-8 Address line 3 *

Only answer if you've selected 'Yes' for field-19-1

19-1-9 Address line 4

Only answer if you've selected 'Yes' for field-19-1

19-1-10 Post code / ZIP code *

Only answer if you've selected 'Yes' for field-19-1

So that we can be sure we're speaking to the right person, please provide a memorable date that will identify the Appointed Guardian when they call.

19-1-11 Appointed Guardian's memorable date *

Only answer if you've selected 'Yes' for field-19-1

Please provide a hint/reminder that we can ask the Appointed Guardian, to help remember their chosen date if they forget - e.g. the Authorised Guardian's birthday or wedding date.

19-1-12 Memorable date hint / reminder *

Only answer if you've selected 'Yes' for field-19-1

Only answer if you've selected 'Yes' for field-01

Declaration

Please read this declaration carefully before signing and dating it. We recommend that you keep a record of all information you supply to us in connection with your child's membership, including letters.

I confirm that all information provided in this application is true and complete to the best of my knowledge and belief. Where applicable, I have confirmed with all persons over 16 years whose information is provided in this form, that the information about them is complete and correct.
I understand that I, the Parent/Legal Guardian, am not entitled to any benefit under the AXA Health Pupil's Healthcare Scheme.
I have informed all persons 16 or over whose information I have provided in this form that I will disclose that information to AXA Health, MMB and the school so that AXA Health can process this application and any claims that may arise.
I understand that it is my responsibility to ensure that any person 16 or over whose information is provided in this form, has read the form.
I understand that if I wish to cancel my child's cover before the start date, I can do so by notifying the school.
I understand that I can cancel my child's cover under the AXA Health Pupil's Healthcare Scheme and receive a refund, as long as I do so in writing to the school within 21 days of cover starting (the 'cancellation period') and no claims have been paid in respect of my child. Any refund that is made during the cancellation period will come from the school. If a claim is made within the cancellation period and a Parent/Legal Guardian still wishes to cancel, then the Parent/Legal Guardian is liable for the premiums for that term. During the period of cover I understand that I wish to end my child's cover under the scheme, I can do so with effect from the end of the current term and that no refund will be paid.
I have parental responsibility for the child named in this application form.
I give my explicit consent for any of the Appointed Guardians named in this form (as applicable) to represent me or my child (if over 16 years) should the Appointed Guardian need to make a claim under the AXA Health Pupil's Healthcare Scheme. If my child is over 16, I confirm that they have given me their consent to appoint Appointed Guardians for them.
I understand that cover will commence from the start of the next school term provided that the school pays the premium and this form is received by the school Term Cut-off Dates of: 30 September, 24 January and 4 May.
I understand that all correspondence will be addressed to my child care of the school, who will pass it to my child for them to act on it. This includes being responsible for passing it to me or any other Parent, Legal Guardian or Appointed Guardian.

20 Please tick to confirm that you have read and accept the information above. *

Only answer if you've selected 'Yes' for field-01

20-1 Additional information

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Data Protection

Important:

AXA PPP healthcare Limited ('we' or 'AXA Health') is the Data Controller of your, your child's, any other Parent or Legal Guardians, and any Appointed Guardian's personal information (collectively, 'personal information') and is responsible for complying with data protection legislation. We have summarised below some key points about how we process personal information to provide the AXA Health Pupils' Healthcare Scheme. More detailed information about how we use personal information more widely and the rights that individuals have over it, is available at axa.co.uk/privacy-policy

How we obtain, use and share personal information

We will process personal information for various reasons, but primarily to provide the services set out under the terms of the AXA Health Pupils' Healthcare Scheme, and to administer it.

Personal information may be provided to us by individuals directly and by healthcare providers - whom we may contact for various reasons, including to clarify an invoice, discuss an extension to a hospital stay, or to obtain copies of medical records. When we need consent to obtain personal information from third parties, we will get it first.

We share personal information with third parties involved with the administration of the Pupils' Healthcare Scheme - see here for more information.

We are obliged to notify the General Medical Council or other relevant regulatory body if we have reason to believe a healthcare provider's fitness to practise may be impaired. This may entail disclosing personal information, including about a child's treatment.

If we, or others, suspect that fraudulent claims have been made or other crimes have been committed, we are legally required to disclose personal information to the relevant law enforcement agencies. We may also disclose information to third parties, including other insurers, to prevent or investigate crime. This includes when there is a reasonable suspicion about fraud or improper claims. This may involve adding non-medical information to databases that other insurers and law enforcement agencies maintain and to which other anti-fraud organisations have access.

22 Please tick to confirm that you have read and accept the information above. *

Only answer if you've selected 'Yes' for field-01

Only answer if you've selected 'Yes' for field-19-01

The AXA Health Pupils' Healthcare Scheme: additional information

Pupils who are over 16 years old

If a child 16 years or over wishes to deal with their own claims and does not wish any parent, guardian, or Appointed Guardian to know about the claim we will respect that on the grounds of confidentiality.

23 Please tick to confirm that you have read and accept the information above. *

Only answer if you've selected 'Yes' for field-19-0

Only answer if you've selected 'No' for field-19-01

The AXA Health Pupils' Healthcare Scheme: additional information

Pupils under 16 years old

AXA Health will not ordinarily deal directly with a child under 16 - any contact with us regarding claims should be made by a Parent/Legal Guardian and/or Appointed Guardian named on this form.

AXA Health may very rarely deal directly with a child under 16 but only after consultation with our Chief Medical Officer.

24 Please tick to confirm that you have read and accept the information above. *

Only answer if you've selected 'No' for field-19-0

Only answer if you've selected 'Yes' for field-01

Application form for Halliford School

School details

Child details

Parent / Legal Guardian details

Appointment of an Appointed Guardian

Declaration

Data Protection

Important:

The AXA Health Pupils' Healthcare Scheme: additional information

Pupils who are over 16 years old

The AXA Health Pupils' Healthcare Scheme: additional information

Pupils under 16 years old