INFORMATION SHEET FOR TYPE B EDUCATIONAL/OFF-SITE VISITS AND ADVENTUROUS ACTIVITIES
Form 3B
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Proposed Visit to:
Castlerigg Manor
Date(s) of visit
Monday 28th October 2019 to Friday 2nd November 2019 at 1.30pm
The proposed activities & educational objectives are:
As per information letter
Mode of transport (incl name of carrier)
Coach
Time and place of departure is:
28/10/2019
Our Lady's Catholic High School
1.30pm
The approximate time and place of return is:
02/11/2019
Our Lady's Catholic High School
1.30pm
The base contact details are (in emergency only)
Name: Mrs R Charnock
Tel: 01772-326900
Additional Information
Copies of written Risk Assessments for the activities (including Plan B) are available on request from the school/service.  

For the visit and the journey to be a valid and safe educational experience, sensible active involvement is required from all participating children.  To ensure that the maximum value is gained the school/service has particular requirements regarding conduct and behaviour.  Your acknowledgement of this is essential (see attached consent form).  If you require any further details, please do not hesitate to contact the school/service.

It is important that parents/carers contact the school/service prior to the visit if there has been any recent illness of which the Visit Leader should be aware.  Furthermore, parents/carers should provide the school/service with any updated medical information and any changes to emergency contact numbers.

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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