Charlton Kings Junior School

CHARLTON KINGS JUNIOR SCHOOL Year 5 PGL Residential Trip to Liddington

PARENT CONSENT AND MEDICAL INFORMATION FORM

We would be grateful if you would complete this form and return it to school as soon as possible. Some of this information is required to meet Health and Safety legislation. All information will be treated as confidential and forms will be destroyed at the end of the visit.

Visit date: 22 – 24 March 2016

Child’s Full Name: ______Date of Birth: ______

Parent/Carer Names: ______

Address:

______

Contact Numbers:

______

Please give the telephone numbers at which you can be contacted during the visit in an emergency (home and work).

Please give details of any illness, injury or disability that might possibly affect the participant’s performance/safety during the weekend, e.g. asthma, hay fever, allergies, epilepsy, diabetes, etc.

______

Is your child currently undergoing medical treatment? Please give details and indicate if they have been in contact with any infectious condition during the month prior to the visit.

______

Please indicate the following for your child:

 Date of their last tetanus injection ______

 Dietary requirements, e.g. vegetarian ______ Whether the participant suffers from enuresis (bed wetting) ______

 Name, address & number of family doctor ______

 The child’s swimming ability/water confidence ______

 NHS number ______

If you are happy for staff to administer the appropriate age-specific dose of sugar-free ‘calpol’ if they feel it was necessary please sign below. By signing you are confirming the child has previously been administered sugar-free ‘calpol’and has never suffered any adverse effect.

I am happy for my child to receive ‘calpol’, signed ______

Please sign below to indicate that:

 You are aware of the nature of the proposed visit to PGL Liddington and the activities offered and that you consent to your child named overleaf participating.

 You undertake to inform us of any change in your child’s fitness prior to the date of your departure.

 You have ensured that your child understands that it is important for their safety and for the safety of others that any rules and instructions given by staff are obeyed.

 You give your consent to School and PGL staff to:

 Allow your child to take any medication specified above  Call a registered medical or dental practitioner to prescribe treatment or medication if required  Administer emergency first aid treatment as necessary

Every effort will be made to contact the parent/guardian in the event of an emergency.

Signature: ______parent/carer

Date: ______

If you have any concerns about the activities or your child’s well-being please do not hesitate to contact the school.