BXM Expeditions Medical Consent Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

BXM Expeditions Medical Consent Form

For DofE Participants at Furze Platt Senior School.

Young people must have parental consent if under the age of 18 years.

The contents of this form will be forwarded to BXM Expeditions for their information. The information provided may be used by BXM Expeditions staff in the event of an emergency and if they need to contact you for any reason.

Data Protection Act: The information being collected on this form will only be used for the purpose of BXM Expeditions administration for the trip associated to this form and will not be used for any other purposes. The data will not be disclosed to any external sources other than in an emergency, or to the Local Education Authority, without your written consent.

Sign in to Google to save your progress. Learn more

Useful dates relating to the expedition section

Please see below some useful dates for your information

- BXM Expeditions Parent Presentation, being held in the Main Hall at Furze Platt Senior School on Tuesday 3rd December 2019 at 6pm (Attendance Mandatory)

- BXM Expeditions one- day training for Bronze, Silver & Gold participants at Furze Platt Senior School- Thursday 19th March

Bronze Expedition dates (Locations are to be confirmed)
- Practice: 12 & 13 June 2020
- Assessment: 3 & 4 July 2020

Silver Expedition Dates (Locations are to be confirmed)
- Practice: 14- 16 April 2020 (Easter holidays)
- Assessment: 25- 27 May 2020 (May half term)

Gold Expedition Dates (Locations are to be confirmed)
- Practice: 14- 18 April 2020 (Easter holidays)
- Assessment: 25- 29 May 2020 (May half term)

Insurance

Participants are covered by BXM Expeditions in the event of negligence by one of its employees or agents. Please be aware that personal belongings or personal injury through inappropriate behaviour is not covered.

Personal Information

Please complete the questions below

Award Level *

Bronze

Silver

Gold

Required

Your child's surname *

Your child's forename *

Your child's address and postcode *

Your child's age *

Your date of birth *

MM

/

DD

/

YYYY

Alternative address & telephone number *

Medical Information:

Please complete the questions below to provide us with relevant information

Has your child, to your knowledge, been in contact with any infectious illness in the last year? *

Yes

No

If yes, please provide details below

Does your child suffer from allergies, diabetes, migraines, epilepsy, bad period pains or any other illness or disability? *

Yes

No

If yes, please provide details below

Is he/ she allergic to anything? (e.g. antibiotics, aspirin or any such medicines, any particular food etc) *

Yes

No

If yes, please provide details below

Is he/ she sensitive to penicillin? *

Yes

No

If yes, please provide details below

Is he/ she receiving any medical treatment at present? (Asthma and hay fever treatment are the responsibility of the student and do not need to be included here) *

Yes

No

If yes, please provide details below

Date of last tetanus injection (or month and year) *

Does he/ she have any special dietary needs? (including any relating to religious beliefs) *

Yes

No

If yes, please provide details below

Name & full address of your child's doctor *

Please complete the information below if your child is taking any medication

Reason for medication 1

Name of medication 1

Route of medication 1

Side effects of medication 1

Dose of medication 1

Frequency/ time of medication 1

Storage instructions of medication 1

Reason for medication 2

Name of medication 2

Route of medication 2

Side effects of medication 2

Dose of medication 2

Frequency/ time of medication 2

Storage instructions of medication 2

If your child is taking medication, the parent/ carer should abide by the statements below

I, the parent/ carer understand that I must deliver the above medication to the instructor on the day of arrival and accept this is a service, which BXM Expeditions is not obliged to undertake

I, the parent/ carer understand that i need to be available for a member of staff at BXM Expeditions to be able to contact me in case of any emergency or for support/ advice in relation to my child's medication and it's management.

Parent/ Carer information

Full name of parent/ carer *

Relationship to the child *

Email address of parent/ carer *

Contact number of parent/ carer (a number BXM Expeditions or a member of staff from Furze Platt Senior School can use to contact you, if necessary, whilst your child is out on expedition *

Parental Consent *

I agree to my son/ daughter taking part in these activities

I understand that the staff responsible for the expedition will take all reasonable care if participants

I consent to any emergency treatment necessary. I therefore authorise BXM Expeditions staff to sign, on my behalf, any written form of consent required by the hospital authorites should medical treatment (a surgical operation or injection) be deemed necessary. Provided that the delay required to obtain my signature might be considered, in the opinion of the Doctor or Surgeon concerned, likely to endanger my child's health or safety

I give permission for photographs of my son/ daughter to be used for school purposes

Required

Thank you for completing this medical consent form

Further information about the expedition will be provided at the Information evening on Tuesday 3rd December at Furze Platt Senior School. If you have any questions relating to the expedition section, please contact one of our colleagues below:

Leigh Rose Logistics Manager, BXM info@bxm.org

Dave Randall Outdoor Education & Enrichment Leader dofe@furzeplatt.org

Duke of Edinburgh Award www.dofe.org

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Furze Platt. Report Abuse