Potters Bar & District Scouts Kandersteg+ 2023 Health Information Form B (For Participants Aged Over 18 on 10 August 2023)

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Please answer the following questions in as much detail as possible.

Privacy Notice

Purpose of Collection: The information you provide in this form is being collected with a view to your medical welfare during the Camp. In the event that you may require emergency treatment, this information will be of assistance to medical authorities in deciding which is the most appropriate treatment to give.

The information collected in this form will be kept confidential save where it becomes necessary to disclose said information to ensure your welfare on the Camp. Information will be deleted one year following the conclusion of the Expedition. You can withdraw your consent at any time by contacting kandersteg2023@pbscouts.org.uk. A statement of your data privacy rights can be found on the Information Commissioner's Office website, www.ico.org.uk.

Your Full Name *

Date of Birth *

YYYY

National Health Service Number *

Date of Last Tetanus Injection *

Can you swim? *

Yes

Emergency Contact - Name and Address during the Camp. *

Emergency Contact - Telephone Number(s) during the Camp. *

Family Doctor's Name, Address and Telephone Number. *

Your Existing Conditions

Please provide details of any Known Infectious Diseases with which you have been in contact within the last three weeks. *

(e.g. Chicken Pox, Diphtheria, Measles, Mumps, Rubella, Whooping Cough etc.)

None

Other:

Please provide details of any known Allergies/Sensitivities/Disabilities and details of any known precautions or remedies. *

(e.g. Penicillin, Food Colourings, Travel Sickness, Asthma etc.)

None

Other:

Please provide details of any Medicines/Diets/Treatments currently being Taken/Followed. *

Including dosage details & the Specialist and Hospital concerned if appropriate (please include any non prescription preparations, such as cough sweets, herbal medicines).

None

Other:

Please provide any further pertinent information in respect of Your Existing Conditions.

Medical Consent

If it becomes necessary for me to receive medical treatment and I am unable to give my consent as a result of illness or injury, I hereby give my general consent to any necessary medical treatment and authorise any member of the Leadership Team to sign all documents required by the hospital authorities.

I will inform the Leadership Team if any of the information given on this form changes (in particular, see the Existing Conditions section above) before the event takes place.

Do you agree to the above Medical Consent? *

Yes

Declaration

By submitting this form you hereby declare that the information provided within is correct to the best of your knowledge.

Your E-mail Address *

Your Address *

Please type your initials and the date in lieu of a signature *

Do you give your consent to the collection and processing of this information as detailed in the Privacy Notice? *

Yes

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