BOOKING/ MEDICAL CONSENT FORM

Section 1: General Details                                                          

Name:                                                                               Age:                                                  
 
 
DOB:                     Sex: M/F

 
Address:

 

Postcode:

 

Tel:

 

Special Dietary Requirements:

 Medical Conditions:

 

 Medication that your child is currently taking:

 

 What, if any, medication is your child allergic to:

 

 Date of last Tetanus injection:

 

Can the above child swim more than 25 metres? YES / NO (If No, are you willing for them to join in suitably supervised water activities YES / NO)

 

 Is there anything else that we should be aware of about your child? (activities you may not wish your child to take part in)

 

 

Section 2: Doctor's Details 

Doctors Name:

Address:

 

Surgery Telephone Number:

 Participant's National Health Number:

 

Section 3: Emergency Contact
Name:                                                                Relationship to Child:  

Address:

 

Telephone Number(s): Home:                                 Work:

 

Mobile Telephone Number:

 

Section 4: Consent

(to be completed by the person with parental responsibility for all participants under 18)

 

I give my permission for                                                       to attend and take part in the above named event. In case of illness or accident, I authorise...   

1.  ...the leader(s) of the event to sign on my behalf any written form of consent required by medical authorities if a delay in obtaining my signature is considered inadvisable or unnecessary by the doctor or surgeon.



2.      the leader(s) to administer prescribed and non-prescribed medication.

 

Signed:

 

Name:                                                                         Date:

 

Relationship to child:

Address (if different to Section 3):

 

 Telephone Number:

 



Denstone College                                              
2nd - 7th April 2008                                                                                                               Cost: £    (cheques payable to Christ Church Clifton) 

Please print off this page and fill in all the details below for each child that is coming on the weekend away. Once complete please return it to Neil Hopkins, 16 Mortimer Road, Clifton, Bristol, BS8 4EY with enclosed cheque. Please note that only payment for residential will confirm place. If you would like to talk about receiving a bursary for your child to attend the residential then contact Neil directly. Thank you.
Due to limited spaces allocation of activities will be on a first come first served basis. Please number the activities in order of preference, with 1 being your first choice. Thank you.

Surfing   .......... Kayacking   ..........                                           Crate towers/ archery..........