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:

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.