Parental Responsibility & Medical Consent Form

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Corporate Parenting Team

PARENTAL RESPONSIBILITY & MEDICAL CONSENT FORM

AltonTowers - Monday 20th October 2014

I agree to the child in my care:

Full Name

Taking part in the above-mentioned trip and, having read the information sheet, agreeto his/her participation in the activities described. Having read the information sheet Ideclare the above child to be in good health and physically able to participate in all of theactivities mentioned. I acknowledge the need for good conduct and responsiblebehaviour on his/her part.

Home address:

Medical Information:

a)Does the above named child suffer from any conditions requiring medical treatment, including medication?

YES / NO

If yes, please give details:

(use additional sheet

if necessary)

b)Please outline the type of pain/flu relief medication your child may be given if necessary.

(for example: paracetemol, ibuprofen, cold/flu powder, flu capsules – please be specific)

c)Is the above named child allergic to any medication (including plasters)?

YES / NO

If yes, please give brief details:

d)When the above named child last receive a tetanus injection?

e)Please outline any behavioural issue, additional need, special dietary or cultural requirements of the above named child:

I will inform the group leader as soon as possible of any changes inthe medical or other circumstances.

G.P. details:

Insurance Cover:

I understand that the visit is insured in respect of legal liabilities (third party liability) but that personal accident cover will not be provided (unless the trip is outside the UK).

Emergency Contacts

I may be contacted by telephoning the following numbers (please include whoever has PR, carers, social worker and team manager):

Name:

Tel. Home: Work Mobile

Name:

Tel. Home: Work Mobile

Emergency Contacts (continued – if applicable)

Name:

Tel. Home: Work Mobile

Declaration

I have read the attached information provided about the proposed visits and theinsurance arrangements.

I understand that any behaviour deemed unsuitable may affect the above named child’s ability to attend the trip.

I agree to the above named child receiving medication as instructed and any emergencydental, medical or surgical treatment, including anaesthetic and blood transfusionsas considered necessary by the medical authorities present.

Signed:

Name:

Signed:

Name:

Photos/Quotes/Media Consent:

I do/ do not give permission for photographic/video images of the above named child to be used in leaflets, displays, on the Beacon and LCC website (including related YouTube, twitter and social media channels) and in local, regional and national media outlets

I do/ do not give permission for quotes from the above named child to be used in leaflets, displays, the Beacon and LCC websites and in various media outlets.

I do/ do not consent to the young person’s name being used in conjunction with the quotes or images.

Signed:

Name: