INFORMATION SHEET FOR TYPE B EDUCATIONAL/OFF-SITE VISITS AND ADVENTUROUS ACTIVITIES
Form 3B
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Proposed Visit to:
D of E Practice and Expedition
Date(s) of visit
1/7/22 - 3/7/22 & 16/9/22 - 18/9/22
The proposed activities & educational objectives are:
1. Complete the Expedition part of the D of E Bronze award
2.
3.
Mode of transport (incl name of carrier)
Redline coaches
Time and place of departure is:
Our Lady's Catholic High School - 1/7/22 9.30am
The approximate time and place of return is:
Our Lady's Catholic High School - 3/7/22 3.30pm
For residential visits only:
1/7/22 - Camping at Guys Farm Activity Centre. 16/9/22 - camping at Cobble Hey Farm
The out of hours supervision arrangements are:
The base contact details are (in emergency only)
Mr M Power
Additional Information
Parental/Carer consent and medical information
This section must be completed.
Pupil's Details
Pupil's Forename *
Pupil's Surname *
Pupil's Date of Birth *
MM
/
DD
/
YYYY
Form/Class *
Emergency Contact Details
Contact's Name *
Contact's Address *
Contact Tel No *
Alternative Contact Name *
Alternative Contact Tel No *
Pupil's Medical Information
Does your child suffer from any of the following?
Asthma *
Required
Bronchitis *
Required
Chest Problems *
Required
Diabetes *
Required
Fainting *
Required
Migraine *
Required
Heart Trouble *
Required
Raised Blood Pressure *
Required
Tuberculosis *
Required
If Yes to any of the above please provide details below.
Does your child suffer with epilepsy? If yes please provide details of the epilepsy syndrome diagnosed and the pattern of seizure.
Has you child been immunised against the following diseases?
Poliomyelitis *
Required
Tetanus *
Required
If yes to Tetanus please give date if known.
MM
/
DD
/
YYYY
Please give details of any medication your child is taking.
In the case of a residential course does your child have?
If Yes to either of the above please give details below.
Insurance Cover
I understand that the visit is insured in respect of legal liabilities (third party liability) but that my child has no personal accident cover unless I have been specifically advised of this in writing by the organiser of the visit. I also understand that any extension of insurance cover is my responsibility unless advised differently by the School.
Declaration by Parent/Carer
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.
I have read the attached information provided about the proposed exchange visit and the insurance arrangements.
I consent to my child taking part in the visit, and, having read the information sheet, declare my child to be in good health and physically able to participate in any activities mentioned.
I have noted where and when the pupils are to be returned and I understand that I am responsible for my child getting home safely from that place.
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/Centre prior to the visit.

I ACCEPT THAT THERE IS AN INHERENT RISK OF INJURY IN PARTICIPATION OF ADVENTUROUS OUTDOOR ACTIVITIES.  RISK CAN BE REDUCED TO ACCEPTABLE LEVELS BY IMPLEMENTING APPROPRIATE RISK ASSESSMENTS.  COPIES OF WRITTEN RISK ASSESSMENTS ARE AVAILABLE ON REQUEST FROM THE SCHOOL.
Name of Parent/Carer *
Address of parent/carer *
By clicking submit you are confirming that all details are correct and consent to your child participating in the trip.
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