Brunswick Football 2021/2022 - U11 & U12 Football Tour - Butlins, Bognor Regis, West Sussex PO21 1JJ - Friday 13th May to Monday 16th May 2022
Parental Consent, Medical Information & Indemnity Form - to be completed by Friday 6th May 2022.
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Email *
CHILD'S DETAILS
Child's first name: *
Child's surname: *
Child's gender: *
Child's date of birth: *
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Current school year: *
Please use numbers only
PARENT / CARER'S DETAILS
Your name: *
Relationship to child: *
Your phone number: *
An emergency contact name and phone number: *
(Someone we can contact in an emergency if we cannot get hold of you)
CHILD'S MEDICAL INFORMATION
Does your child suffer from any ailments, eg diabetes, epilepsy, asthma, hay fever, etc.? *
If YES, please give details:
Does your child take any regular medication or are they receiving any medical treatment at present? *
If YES, please give details:
Please be aware that, if requested to do so, we will only administer prescribed medication to your child
Is your child allergic to anything, eg antibiotics, aspirin, penicillin, or any other drugs, foods, or insects? *
If YES, please give details:
Does your child have any special dietary requirements that we need to know about? *
If YES, please give details:
Is there anything else we would need to know about your child that has not been covered, e.g. special needs, court orders, challenging behaviour, etc.? *
If YES, please give details:
PERMISSIONS
I give permission for my child to take part in The Brunswick Football 2021/2022 - U11 & U12 Football Tour - Butlins, Bognor Regis, West Sussex PO21 1JJ - Friday 13th May to Monday 16th May 2022.  I understand that this will involve travel by coach or minibus and I acknowledge the need for responsible behaviour on my child's part.
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I give my consent that in an emergency The Brunswick Club may act in my place (in loco parentis) if the need arises for the administration of emergency first aid and / or other medical treatment which in the opinion of a qualified medical practitioner may be necessary. *
I acknowledge and agree that neither The Brunswick Club nor the leaders in charge can be held responsible or liable to compensate for the loss of or damage to any of my child’s personal belongings and that my child is always responsible for the safe custody thereof. *
I indemnify The Brunswick Club and the leaders in charge from and against any liability, costs, claims or expenses howsoever arising whether directly or indirectly as a result of any accident, injury or illness which my child may suffer or sustain which is not due to the negligence of the Club or leaders in charge where the said accident, injury or illness or other damage is a result of my child disobeying any lawful, reasonable instruction(s) which may be given to him or her by the Club or the leaders in charge. *
Do you consent for your child having their photograph taken during activities and for these to be used for Brunswick and any other related publicity? *
I understand that by completing this form, the details I have provided will be taken, stored, and processed by The Brunswick Club in accordance with the Club's Data Protection Policy. *
Signed (your full name): *
Date *
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When you submit this form you will receive an automatic email from Google Forms.  This is  a record of the information you have supplied to us and acts as confirmation that we have received your form.  If you do not receive this email, please check your Junk folder.  If you are unsure whether we have received your form, please email: membership@thebrunswickclub.org.uk.  Thank you.
A copy of your responses will be emailed to the address you provided.
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