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:
Holiday Consent
Date of Residential/ Holiday: