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Form 3A
Parental/Carer Consent and Medical Information Form for Type A Educational/Off-Site Visits (This form is to be completed in full by the parent/carer and returned to the school)
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I agree to my son/daughter/ward taking part in the above stated visit/activity and having read the information sheet, agree to his/her participation in any or all of the activities described. I acknowledge the need for good conduct and responsible behaviour on his/her part and that the school/service reserves the right to prevent my son/daughter/ward continuing with the visit/activity in the case of poor behaviour. Further, I understand that there would be no entitlement to a refund of monies paid. I agree that I will update the school/service with any medical information or changes to emergency contact details.
*
Yes
No
Required
Pupil Details
Pupil Forename
*
Your answer
Pupil Surname
*
Your answer
Form
*
Your answer
Details of Visit
Harris Museum and Avenham Park
Visit To
Harris Museum and Avenham Park - 23rd September at 9am
Alternative Activity (Plan B)
Date of Trip
23rd September
Consent Statement
By continuing to complete this form you are agreeing to the statement below:
I agree to my son/daughter/ward taking part in the above stated visit/activity and having read the information sheet, agree to his/her participation in any or all of the activities described. I acknowledge the need for good conduct and responsible behaviour on his/her part and that the school reserves the right to prevent my son/daughter/ward continuing with the visit/activity in the case of poor behaviour. Further, I understand that there would be no entitlement to a refund of monies paid. I agree that I will update the school with any medical information or changes to emergency contact details.
Emergency Contact Details
Contact Name
*
Your answer
Contact Address
*
Your answer
Contact Telephone Number
*
Your answer
Alternative Contact
Please state an alternative contact point:
Alternative Contact Name
*
Your answer
Address
*
Your answer
Telephone Number
*
Your answer
Other Information: Please supply any additional information that you wish the Visit Leader to be aware of (e.g. medical conditions, allergies, recent illness, special requirements etc) which may affect him/her in this visit:
Your answer
Declaration by Parent/Carer (Please answer all questions)
In the case of an emergency I agree to my child being given any medical, surgical or dental treatment, including general anaesthetic and blood transfusion, as considered necessary by the medical authorities present.
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Yes
No
I consent to my child taking part in the visit and, having read the information sheet, I declare my child to be in good health and physically able to participate in any activities mentioned; subject to any agreed adjustments.
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Yes
No
I have noted where and when the children are to be returned and I understand that I am responsible for my child getting home safely from that place.
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Yes
No
I will ensure that any change in the circumstances (e.g. recent illness, medication or injury) which will affect my child’s participation in the visit will be notified to the School prior to the visit.
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Yes
No
I have read and understood the School's behaviour contract.
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Yes
No
Name of Parent/Carer
*
Your answer
Address (if different from above)
Your answer
Verification
By clicking Submit you are confirming that all details contained within this form are correct
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This form was created inside of Our Lady's Catholic High School.
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