Home > Youth > Youth Retreat 2012 > Medical Form

Medical Form

St Leonard’s Church, Chesham Bois

RESIDENTIAL PARENTAL CONSENT – PLEASE RETURN A.S.A.P.

Activity: Youth Retreat 2012

Member’s name: …………………............... Date of birth:...........................................

Visit to: The Frontier Centre, Northants

I agree to ………………………… (name) taking part in this visit and have read the information sheet. I agree to his/her participation in the activities described. I acknowledge the need for him/her to behave responsibly.

Medical information about your child

Any conditions requiring medical treatment, including medication? YES/NO

If YES, please give brief details:

……………………………………………………………………………………………..

Please outline any special dietary requirements of your child and the type of pain/flu relief medication your child may be given if necessary:

……………………………………………………………………………………………..

……………………………………………………………………………………………...

To the best of your knowledge, has your child been in contact with any contagious or infectious diseases or suffered from anything in the last four weeks that may be contagious or infectious?

YES/NO

……………………………………………………………………………………………..

Is your son/daughter allergic to any medication? YES/NO

If YES, please specify

……………………………………………………………………………………………..

When was the last time your child received a tetanus injection?

………………………………………………………………………………………

Declaration

I agree to my son/daughter receiving medication as instructed and any urgent dental, medical or surgical treatment, including anaesthetic or blood transfusion, as considered necessary by the medical authorities present.

I will inform the Group Leader as soon as possible of any changes in the medical or other circumstances between now and the commencement of the journey.

Signed: ……………………………………………. Date: ……………………………….

Full name (capitals): ………………………………………………………………………..

Relationship: …………………………………………………………………………………

Contact telephone numbers:

I may be contacted during the trip by telephoning the following numbers:

Mobile: ………………………………………… Home:……………………………. Home address: …………………………………………………………………………

………………..………………………………………………………………………….

If I am not available at above, please contact:

Name:……………………………………… Tel No:……………………………..

Address: …………………………………………………………………………………

…………..…………………………………………………………………………………

Name and address of family doctor:

Name: …………………………………………. Tel No: ……………………………..

Address: ………………………………………………………………………………….

……………………………………………………………………………………………..

This form, or a copy, must be taken by the group leader on the visit. A copy should be retained by the Church Office