EAST SUSSEX PONY CLUB SENIOR CAMP 2016 APPLICATION

SENIOR CAMP 12 – 25 years (Children to be 12 and over on 14th August 2017)

At Ardingly Show Ground, from Monday 14th August 2017 to 19th August 2017

This form is to be completed by the Parent / Guardian of each Pony Club Member. One form per child.

Name of Member ______

Date of Birth ______Age as at 14th Aug 2017______First time to senior camp YES/NO

Name of Parents / Guardian ______

Address of Parents / Guardian ______

______

Tel. Number (Day)______(Night) ______

Fax Number ______Email______

Authorized contact if parent unattainable ______Tel. No.______

Member’s General PractitionerNAME______

NAME & ADDRESS OF PRACTICE ______

______TEL:-______

Does he / she suffer from:

* AsthmaYES / NO* Epilepsy / FaintingYES / NO

* MigraineYES / NO* DiabetesYES / NO

* DyslexiaYES / NO* Hay FeverYES / NO

* Heart / Lung DisorderYES / NO* Bone / Joint ImpairmentYES / NO

* Vision / Hearing DefectsYES / NO* Allergy to Drugs / FoodYES / NO

* Gynaecological DisordersYES / NO* Ear, Nose & Throat YES / NO

* Gastro-intestinal DisordersYES / NO * Any skin complaintYES / NO

Are contact lens worn ?______Religion, if applicable to Medical Treatment ______

Any other problem of which the Welfare Officer should be aware? ______

______

Does he / she regularly take any form of Medication, if so what? ______

Are there any current injuries / recent operations / medical treatments?YES / NO If so, please explain.

Any previous operations, e.g., appendix YES / NO If so, please explain

Date of last Tetanus Injection ______(Any adverse reaction?)

Blood Group (if known)______Is he / she a VegetarianYES / NO

Does he / she have any special dietary or other requirements ? ______

Are there any foods your child does not like? ______

In the event of my daughter/son requiring emergency medical or dental treatment whilst taking part in the Pony Club activity as described above, and an Officer or other responsible adult being unable to contact either myself or other person with a parental responsibility for my daughter/son, I hereby authorise the District Commissioner or other Officer of the Pony Club to obtain such medical or dental treatment for my child as they, in their absolute discretion, think necessary after consultation with a medical or dental practitioner. This authority extends to all medical and dental treatment including the giving of an anaesthetic where necessary.

Signed ______Date ______

We would like all members attending Senior Camp to have attained their D+ test as a minimum requirement. Please indicate which test you have passed:-

D+ / C / C+ / B
B+ / LUNGING / AH / A