IRONBRIDGE 2018 – Contact/Medical and Information Form.

PLEASE RETURN AS SOON AS POSSIBLE BUT NO LATER THAN

Monday 29th January

Name of child
Date of birth
Home telephone number
Work telephone number
Mobile telephone number
Contact number and dates if away from home during the trip
Doctor’s name
Doctor’s address
Doctor’s phone number
Please indicate if your child has any of these conditions
Asthma or bronchitis / Yes / No
Heart condition / Yes / No
Fits, fainting or blackouts / Yes / No
Severe headaches / Yes / No
Diabetes / Yes / No
Known allergies to any medication. Please indicate what type of medication / Yes / No
Any other allergies, food, insect bites, material etc. / Yes / No
Any other illness or disability we should be aware of / Yes / No
Any recent contact with contagious diseases or infections / Yes / No
Please confirm the following
Has your child received a vaccination against tetanus in the last 5 years / Yes / No
Is your child currently receiving any medical treatment? Please see attached form. / Yes / No
Has your child been given any medical advice to follow in emergencies / Yes / No
If you have answered yes to any of the above, please provide full details overleaf.
It is the practice on activity holidays for the staff to administer mild analgesics/anti-histamine (for example Calpol/Piriton) to children when necessary.
I give my consent for my child to receive mild analgesics and mild anti-histamine (e.g. Piriton) if necessary / Yes / No
If my child is ill or his/her behaviour is unacceptable or compromises the safety of other pupils, I will come and collect my child if requested to do so. / Yes
My child requires a vegetarian diet / Yes / No

I understand that steps will be taken to inform me immediately should any accident or emergency arise. I authorise Miss George (or any member of Tillingbourne or Ironbridge staff) to give permission for such medical treatment as needed.

.Signed: ...... (Parent/guardian) Date......

Medicine Form Child’s Name: ______

PLEASE BRING THIS FORM TOGETHER WITH ANY MEDICATION ON THE MORNING OF THE TRIP AND GIVE TO MRS HERN IN THE ENTRANCE HALL

Parents to fill in this section of the form please

Medical Condition / Medication / Dose / Frequency

This table will be filled in by staff on the trip

Tick when given / Teacher initials and any notes
Tuesday
Wednesday
Thursday
Friday