I give consent to my child taking part in activities/visits and have read the information sheet. Iunderstand that I am responsible for updating this form if required. I acknowledge the need for them to behave responsibly. Student name & Tutor Group:Student Forename(s): Surname(s): Please select your child’s Tutor Group: – Select –7BAY7MG8HST8HT10MC10TA10WV11CD11CP11HM11LL12FT12HN/KIB13EX/KIB13LMCicely Saunders MORDesmond Tutu OLDorothy Day HSTMartin Luther King BXMaximillian Kolbe MGMother Teresa ONOscar Romero HTSean Devereux SNTrevor Huddleston GIJ 1. Visits/activities Is your child entitled to free school meals? Yes No Medical information about your child: a. Is your child affected by any illnesses or disablities relevant to school visits? Yes No If Yes please give details: b. Is your child currently taking any medication? Yes No If Yes please give details: c. Is your child currently receiving medical treatment? Yes No If Yes please give details: d. What type of pain relief medication may your child be given if necessary? e. Is your child allergic to anything? Yes No If Yes, please specify (severity,treatment etc): f. Please outline any special dietary or other requirements of your child: g. Date of last anti-tetanus injection? I will inform the Academy as soon as possible of any changes in my son/daughter’s medical or other circumstances. For activities that include swimming Is your child: Able to swim 50m? Yes No Water confident in a swimming pool? Yes No Confident in the sea or open water? Yes No Safety conscious in water Yes No Contact telephone numbers: Mobile: Work: Home: Address: House Name/Number: Street: Ward (optional)(e.g. Priorslee or Donnington): Town/City: Postal Code: Alternative Emergency Contact Name: Telephone Number: Address: House Name/Number: Street: Ward (optional): Town/City: Postal Code: GP/Consultant Information GP/Consultant’s Name: Telephone Number: Address: Declaration I agree to my son/daughter receiving medication as I have instructed. I authorise leaders and first aiders on school vists to give permission for my child to receive any emergency dental, medical or surgical treatment, including the administration of anaesthetic as considered necessary by the medical authorities present if this should occur at a time when my consent to the particular treatment cannot otherwise reasonably be obtained. Note: If there are medical treatments you will not consent to, please ensure that you tell the academy about these and attach details to this form. I understand the extent and limitations of the insurance cover provided. To view our Public Liability Cover; click here. Your Name: Date: This form or a copy must be taken by the party leader on the visit. A copy should be retained by the school home base emergency contact.