Offsite Visits Personal & Medical Information and Parental Consent Form

CONFIDENTIAL
VISIT DETAILS

Description of Activity.............................................................................................................
Departure and Return Dates............................................to.....................................................
Venue.........................................................................................................................................
INFORMATION FOR PARENTS/GUARDIANS/CARERS
Please complete the questions below and sign the consent. The personal and medical information requested is vital to ensure that appropriate care and support is available for each child. Please consult your family doctor if you are unsure about the suitability of a visit. Medical conditions will not necessarily exclude any child from participating in activities, but leaders should be made aware of anything that might affect the safety/welfare of this child or others in the group.

PERSONAL DETAILS
Name of Child.....................................................Date of Birth.................................................
Address......................................................................................................................................
...............................................................................Postcode.....................................................
Parent(s)/Guardian(s) Name....................................................................................................
Address (if different from above)............................................................................................
..............................................................................Postcode.......................................................
Telephone Numbers:

Day..............................................................................................
Evening......................................................................................
Mobile.........................................................................................

Additional Emergency Contact:

Name...............................................................................
Relationship...................................................................
Telephone Number(s)....................................................
....................................................

DIETARY INFORMATION
If this child has any specific dietary needs (e.g. vegetarian), please give details here:

MEDICAL or SPECIAL NEEDS
Please provide all relevant information which will enable the Visit Leader to safely care for this child:
Yes No
Does this child have any significant allergies (including to medication)?
Yes No
Does this child have any medical conditions, impairments, or disabilities?
Yes No
Has this child had any recent significant illnesses or injuries?
If a residential visit, does this child have any night-time tendencies (e.g. sleepwalking,
Yes No nightmares, bed-wetting) which might cause him/her concern?
If the answer is “yes” to any of the above questions, please give full details below (use an additional sheet if necessary):

Appendix 4 – Info&Consent Form

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Last updated September 2011

PERSONAL MEDICATION
It is important that this child is accompanied by any medication necessary, and that leaders are fully informed. Please make sure that there is sufficient medication, and that it is clearly labelled.
Time and Frequency
Method of
Name of medication
Dosage
or circumstances to
Administration
be given

Please state any special precautions, or side effects of medication (if applicable):

I give my consent* for a member of staff to administer the above medication which I will deliver to the Visit Leader before the visit, together with clear labels and instructions. I understand that the