Brighton and Hove City Council

BRIGHTON AND HOVE CITY COUNCIL CHILDREN AND YOUNG PEOPLES TRUST

OFFSITE ACTIVITY MEDICAL AND CONSENT FORM

Full Name Of Establishment/Project IMPORTANT The parent or guardian must Liddington residential complete this form if the St Mary Magdalen’s Catholic Primary School participant is under 18 years of age and by the participant of he/she is over 18 years of age.

Name of Participant Male/Female Data Protection Act 1998 Your details will be kept within the records of the Establishment. We will keep your records to inform you of any subsequent trips/activities that Address of Participant we feel may be of interest to you. We may contact you from time to time, but we WILL NOT pass your details on to any other organisation. You can have your details removed at Telephone Number (incl. STD) any time by contacting us. During the course of the trip/activity there may be times when photographs are taken of young people for publicity reasons. If you do not wish photographs to be taken Participant’s Date of Birth of the young person named above, please tick this box: 

Contact for Next of Kin (Name and Address) Details of last tetanus injection:

Next of Kin’s Telephone Numbers (incl. STD): Have you had one in the Home last 10 years?

Work YES/NO

Mobile

Relationship to Participant Contact for Doctor (Name and Address)

Doctor’s Telephone Number Do you consider that you Please give details To which of these have a disability? of any current groups do you consider medical treatment you belong? (Please tick Please circle as required: including one box) None medication: Dyslexia/Learning Difficulties White  Black  Blind/Partially Sighted Deaf/Hard of Hearing Asian  Mixed  Wheelchair Use/Mobility Problems Chinese  Need Personal Care or Assistance Details of any Other ……………………. Mental Health Difficulties special dietary Unseen Disabilities eg. requirements or Diabetes, Allergies, Epilepsy, dislikes: Asthma or Heart Condition or other disability not listed above (please state) ……………………………………. ……………………………………. ……………………………………. STATEMENT I ACKNOWLEDGE RECEIPT OF AND UNDERSTAND THE INFORMATION REGARDING THE PROPOSED VISIT/ACTIVITY TO Liddington AND CONSENT TO …………………………………………(child’s name) PARTICIPATING. I have ensured that my child/I understand(s) the information below and for his/her/my safety and for the safety of the group that any rules and instructions given by staff are obeyed. I understand to inform the leader of any changes in the fitness of the participant/myself prior to the date of departure. I am in agreement that those in charge may give permission for the participant/me to receive medical treatment in an emergency.

Signed: ……………………………………….. (Parent/Guardian/Participant) Date: ……………………….

I understand that for the groups and my own safety, I will understand to obey the rules and instructions of members of staff.

Signature of Participant: ………………………………… Date: ………………………...

PLEASE RETURN THIS FORM TO THE TRIP LEADER AT THE ESTABLISHMENT