| Name of Organisation
________________________________________________ |
| Event
______________________________________________________________ |
| Date/Time from ________________________ to
___________________________ |
| Leader(s) in charge
__________________________________________________ |
| Name of Child / Young Person
__________________________________________ |
| Home Address
______________________________________________________ |
| Telephone Number(s)
_________________________________________________ |
| Date of Birth________________ |
| Passport No. ________________________ |
Doctor's name and address
____________________________________________
|
| Doctor's Telephone ________________________ |
| Date of last anti-tetanus injection (if known)
______________________________ |
- Has he/she been in contact with any infectious disease within the past three
months? Yes No
- Is he/she taking any medicine that needs to be continued during the visit?
Yes No
- Does he/she suffer from any allergies, recurrent illness, bad period pains
or other illness or disability? Yes No
|
| Other relevant medical
details:__________________________________________ |
| Special dietary
requirements:___________________________________________ |
- I have been notified of the travel arrangements and the rules for the visit.
- I have seen the programme of events.
- I have been notified of the name and address of our child's hosts.
- I agree to reimburse the organisers for any out-of-pocket expenses incurred
in dealing with difficulties or incidents for which my child is responsible,
including accompanying my child back home following serious misconduct.
|
I hereby give consent for the child named above to
take part in the activities of the event named above. In the event of a
medical emergency I authorise the Leader named above to sign any consent form
considered necessary by hospital authorities,
if the delay required to obtain my own consent is considered inadvisable by the
doctor or surgeon concerned. |
Signed
______________________________________________Parent / Guardian
|
| Name ______________________________ Date
___________ |
