PARENTAL CONSENT FOR A SCHOOL VISIT

Name:…………………………………………Form……..

1                 Details of visits:    Nursery to Hardwick Park 2014

I agree to ……………………………….. taking part in this visit and have read the information sheet.

I agree to my child participating in the activities described.

I acknowledge the need for my child to behave responsibly.

2          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 may be given, if necessary:                    ………………………………………………………………………………………………….

(c)       Please give details of any other health/behavioural information which would be useful to the   group leader:

…………………………………………………………………………………………………

(e)       Is your son/daughter allergic to any medication?                                                     YES/NO

If yes, please specify:

………………………………………………………………………………………………….

(f)        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.

2                 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.

I acknowledge £5.70 will be added to the next school fee bill.

Contact telephone numbers:

Work:  ……………………………………………Mobile:…………………………………

Home:…………………………………………….

Address:  ………………………………………………………………………………………..

………………………………………………………………………………………………………….

Alternative emergency contact:

Name:  …………………………………………….  Tel No:  ………………………………………..

Name of Family Doctor:  ……………………………………………………………………………..

Tel No:  ……………………………………………………………………………………………….

Signed:  ……………………………………………  Date:  ……………………………………….….

Full Name:  …………………………………………………………………………………………….

(In capital letters please)

THIS FORM, OR A COPY, MUST BE TAKEN BY THE GROUP LEADER ON THE VISIT.

A COPY SHOULD BE RETAINED BY THE SCHOOL CONTACT.