Yr 9 Camp Consent Form

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Student Forename* Student Surname* Form Group* Student Date of Birth DD/MM/YY*

Please select the trip that your son will be attending:*Yr 9 Camp - Weds 16th - Fri 18th May 2018DofE - Weds 16th - Fri 18th May 2018

Student Contact Details and Medical Information


Home Address

Please enter the details of the main contact (for the duration of the visit/trip)

	Name	Mobile number	Other contact number

	Name	Mobile number	Other contact number

Other contact's relationship to student Medical information

	Name of doctor	Telephone number	Surgery address

Please tick the box below if your child does NOT suffer from any medical condition requiring regular treatment or medication.

If your son DOES suffer from medical issues requiring treatment or medication, please complete the following: If your son DOES suffer from medical issues requiring treatment or medication, please state the conditions below: Prescription medication

	Name of medication	Dose taken	Frequency
Medicine 1
Medicine 2
Medicine 3

Does your son take over the counter medication for any reason?*YesNo

If YES, please enter details below

	Medicine name	Dose taken	frequency
Medicine 1
Medicine 2
Medicine 3

Does your child have any allergies that staff may need to be aware of?*YesNo

if YES, please enter details below

	Type of reaction	Treatment / medication required
Allergy
Allergy
Allergy

Would you like to discuss your child's medical conditions or allergies with the teacher in charge?*YesNo

Does your child have an up to date tetanus immunisation?*YesNo

Are you willing for your child to be given 'over the counter' medication by staff e.g. paracetemol, throat lozenges, plasters, insect bit antihistamine?*YesNo

Any medication required should be given to the teacher in charge, clearly marked (in its prescription container if possible) with name and full instruction for use.

Inhalers and 'Epipens' may be kept by the pupil with spares given to the teacher in charge.

Does your child have any specific dietary requirements? e.g vegetarian, hala, kosher etc.*YesNo

If YES, please give details. Please include any additional information as required.

Declaration by Parent/Guardian

1. I have read and completed this form and to the best of my knowledge the details given are true and accurate.

2. I agree to my child receiving medication as instructed and any emergency dental, medical or surgical treatment, including anaesthetic or blood transfusion, as considered necessary by the medical authorities present.

3. I will inform the teacher in charge as soon as possible of any changes in the medical or other details between now and the commencement of the visit/trip.

Parent name:* Date DD/MM/YY*

I give consent to my child attending the trip.*YesNo

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