Parental Consent
PARENTAL CONSENT FOR A SCHOOL VISIT
(to be distributed with an information sheet giving full details
of the visit)
School /Group: __________________________
Details of visit
to:________________
From:______ Date/Time:______ To:______ Date/Time:______
I agree to _____________________________ (name)
taking part in this visit and have read the information sheet.
I agree
to_______________________’s participation in the activities
described.
I acknowledge the need
for_______________________ to behave responsibly.
Medical information about your child
a) Any conditions requiring medical treatment, including
medication?
YES/NO
If YES, please give brief details:
_______________________________________
_______________________________________
_______________________________________
b) Please outline any special dietary requirements of your child and
the type of pain/flu relief medication your child
maybe given if necessary:
_______________________________________
_______________________________________
_______________________________________
For Residential visits and exchanges only
c) To the best of your knowledge, has your son/daughter been in contact
with any contagious or infectious diseases or suffered from anything in
the last four weeks that maybe contagious or infectious?
YES/NO
If YES, please give brief details:
_______________________________________
_______________________________________
_______________________________________
d) Is your son/daughter allergic to any medication?
If YES, please specify: YES/NO
_______________________________________
_______________________________________
_______________________________________
When did your son/daughter last have a tetanus injection?
_______________________________________
I will inform the Group Leader/Head Teacher as soon as possible of any
changes in the medical or other circumstances between now and the commencement of the
journey.
Declaration
I agree to my son/daughter 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. I understand the extent and
limitations of the insurance cover provided.
Contact telephone numbers
Work :_______________________________________
Home:_______________________________________
Home address:________________________________
____________________________________________
____________________________________________
Alternative emergency contact:
Name:_______________________________________
Telephone number:____________________________
Address:_____________________________________
____________________________________________
____________________________________________
Name of family doctor:_________________________
Telephone number:____________________________
Address:_____________________________________
____________________________________________
____________________________________________
Signed:_____________________________________
Date:_______________________________________
Full name (capitals) ________________________________________
THIS FORM OR A COPY MUST BE TAKEN BY THE GROUP LEADER ON THE VISIT.
A COPY SHOULD BE RETAINED BY THE SCHOOL CONTACT.
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