Off-Site Activity Medical and Consent Form
Furze Platt Junior School

IMPORTANT: This form MUST be completed by the parent/guardian if the participant is under 18 years of age.
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Participants First Name: *
Participants Surname: *
Gender: *
Address of Participant: *
Participants Date of Birth: *
Emergency Contact Telephone Number: *
Emergency Contact Details | DURING PERIOD OF ACTIVITY *
Doctor's Details:

Please include Doctor's name, full address and telephone number.
 *
Please give details of any medical conditions / disabilities, e.g. diabetes, epilepsy or allergies to (e.g.) medication, plasters etc.

Please give current treatment including medication.

Details of any specific dietary requirements.

Details of last Tetanus Injection date.
 *
STATEMENT

I ACKNOWLEDGE RECEIPT OF AND UNDERSTAND THE INFORMATION REGARDING THE PROPOSED VISIT  ACTIVITY TO ANY ORGANISED BY THE SCHOOL AND CONSENT TO THE ABOVE PERSON PARTICIPATING.

I have ensured that my child / I understand (s) the information for their / my safety and for the safety of the group that any rules or instructions given by staff are obeyed. I undertake to inform the Leader of any changes in the fitness of the participant / myself prior to the date of departure.

I accept full financial responsibility of they / I have to return home before the end of the trip because of inappropriate behaviour.

I am in agreement that those in charge may give permission for the participant / me to receive medical treatment in an emergency.
 *
Required
Signed: *
Date: *
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