Consent Form for an Activity

Child's Details

Child's Full Name*

First Last

Child's Date of Birth*

Nature of Event / Activity: one social outing (Bowling and then lunch), and one full day retreat

Description, please write below: one social outing (Bowling and then lunch), and one full day retreat*

Date

Emergency Details - Contact 1

Full Name*

First Last

Relationship to Child/Young Person:*

Daytime Contact Number

Evening Contact Number

Mobile Number*

Do you have parental responsibility for the child/young person?*

Yes

If not, name and contact details for person with Parental Responsibility

Emergency Details - Contact 2

Full Name

First Last

Relationship to Child/Young Person:

Daytime Contact Number

Evening Contact Number

Mobile Number

Do you have parental responsibility for the child/young person?*

Yes

If not, name and contact details for person with Parental Responsibility

Child/Young Person’s Doctor

Name of Surgery*

Name of Doctor*

Child’s NHS Number (if known)

Address

Address Address Line 2 Town County Post Code Country

Code of Conduct

I understand that all leaders and helpers will be expected to adhere to the Code of Conduct.*

Yes

I acknowledge the need for my child also to behave responsibly and will ensure that this expectation to behave in accordance with the Code of Conduct for Young People is fully understood by my child*

Yes

Medical Information - Medications

Does your child have any condition/s requiring the administration of medications or other treatment?*

Yes

If yes, please give details

I confirm that I have discussed management/administration/storage of medications with the event leader.

Yes

Medical Information - Immunisations

Please confirm whether your child has had the governmentally recommended immunisations for their age?*

Yes

Date of most recent Tetanus immunisation

Medical Information - Allergies

Please detail your child’s known allergies*

My child has an EpiPen

Yes

I confirm that I have discussed its management/administration/storage with the event leader

Yes

Medical Information - Dietary Requirements

Please list any dietary requirements, both due to intolerance and personal beliefs*

Medical Information - Pain Relief

In the event that your child has a fever or is injured and we need to give pain relief, are there specific indications about the type of pain relief used and dosage?*

Medical Information - Additional Emotional Needs

Does your child have any additional emotional needs, other than the usual needs of a child their age? For example, have they suffered trauma, have any fears or phobias, or any medical conditions that affect their behaviour?*

We will use this information to help responsible adults to support your child should any difficulties arise.

Medical Information - Additional Physical Requirements

Is there any other relevant information/specific requirement/s that needs to be known? (e.g. travel sickness/mobility requirements)*

Medical Information - Contagious Diseases

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 few weeks that may be contagious?*

Transportation

Please complete full details as to how your child will travel, including name and contact details of person(s) responsible for transportation/drop-off/collection:

To and from the activity or pick-up point

If relevant, during the activity or trip:

Communication with child/young person (over 13 years only)

Please tick each method of communication with your child that you consent to. Where you consent to electronic methods of communication, please provide your own account address so that you can be copied into the correspondence.

Telephone

Yes

Phone Number

Yes

Any others?

Yes

Details

Statement of Consent

I give my express consent to my child, as named above, participating in the activities detailed in this form

Signature*

Parent/Carer’s Full Name*

First Last

Date*

Child's Details

Nature of Event / Activity: one social outing (Bowling and then lunch), and one full day retreat

Emergency Details - Contact 1

Emergency Details - Contact 2

Child/Young Person’s Doctor

Code of Conduct

Medical Information - Medications

Medical Information - Immunisations

Medical Information - Allergies

Medical Information - Dietary Requirements

Medical Information - Pain Relief

Medical Information - Additional Emotional Needs

Medical Information - Additional Physical Requirements

Medical Information - Contagious Diseases

Transportation

Communication with child/young person (over 13 years only)

Statement of Consent

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