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.