Residential Visit Consent & Medical Information Form

This form must be signed by the parent/guardian/carer (unless the participant is over 16 years of age and living independently, in which

case they should complete and sign themselves). Please return to the Visit Leader in advance of departure.

Details of Visit (To be completed by establishment.)

Title of Visit:

Duke of Edinburgh Bronze Practice Day Hike

Date(s):

Friday 22nd/23rd June 2018

Location:

White Peak, Derbyshire

Nature of Activities:

Hiking

Mode of Transport:

 Mini bus

Details of Participant                                          Emergency Contact Details of Parent/Carer/Guardian

Surname:

Name(s):

Forename:

Relationship:

Date of Birth:

Home Phone:

Gender:

Mobile(s):

Address:

Work Phone:

Address:

(If different from participant during visit.)

Post Code:

Dietary Information

Please indicate any food allergies or dietary requirements e.g. vegetarian.

Swimming and Water Confidence (Please answer Yes or No by deleting as appropriate.)

It may not be necessary for participants to be able to swim on a visit or activity, but for some visits, they may need to be water confident. Please indicate their ability and confidence.

Water confident?

Yes / No

Able to swim at least 25 metres?

Yes / No


Doctor’s Information

Name of Doctor:

Telephone Number:

Address:

Medical/Behaviour Information (Please answer Yes or No to each statement by deleting as appropriate.)

Has the participant had any serious illness within the last three months?

Yes / No

Is the participant recovering from an accident, broken limb or injury of any kind?

Yes / No

Does the participant have epilepsy, convulsions, seizures or absenting of any kind?

Yes / No

Does the participant have any specific anxieties

Yes / No

Does the participant suffer from travel sickness?

Yes / No

Is the participant asthmatic?

Yes / No

Is the participant diabetic?

Yes / No

Does the participant have any type of heart condition?

Yes / No

Any allergies including historical reactions to medication or plasters?

Yes / No

Is there any additional medical (including historical), behavioural or other condition?

Yes / No

Does the participant have any night time tendencies such as sleepwalking, bed-wetting, etc?

Yes / No

If you have answered ‘Yes’ to any of the above or wish to provide more information, please provide details below or attach additional information:

When did the participant last have a tetanus injection?

Date:

If not known tick here    

Do you consider the participant to be physically and medically fit to participate in the visit?

Yes / No


Medical Treatment Whilst Participating in the Visit (Please answer Yes or No by deleting as appropriate.)

Participants sometimes need treatment for minor ailments e.g. headaches, insect bites, sunburn, cuts/grazes etc. If deemed necessary, do you give permission for establishment staff to treat such ailments with the following ‘over the counter’ products: paracetamol, antiseptic cream, calamine lotion, antiseptic wipes, insect bite antihistamine, sun cream, plasters?

Yes/No

If you have answered ‘No’ to the above, please state clearly below which of the products listed above you do not wish the participant to be given (or if other alternatives are acceptable or preferred instead):

Prescribed Medication (Please answer Yes or No by deleting as appropriate.)

Is the participant taking any prescribed medication?

Yes / No

If you answered ‘Yes’ to the above question please read and complete the section below:

It is important that this child is accompanied by any medication necessary, and that leaders are fully informed. Please make sure that there is sufficient medication, and that it is clearly labelled.

Name of Medication

Dosage

Time & Frequency

Method of Administration                                                    

I give my consent* for a member of staff to administer the above medication which I will give to the Visit Leader before the visit, with clear labels and instructions. I understand that the staff on the visit are not qualified medical practitioners, but that they will take reasonable care in the administration of the medication.

I give my consent* for this participant to self-administer the above medication.

(*delete if not applicable)

Consent

I have received full information about the visit, understand the nature of the visit and consent to the participant engaging in all of the activities described. I understand that the visit may be changed by the Visit Leader due to weather or other reasons. I understand and accept that there is some level of risk in every activity, but that all reasonable measures will be taken to minimize the risks involved and I will ensure that the participant understands that they must behave responsibly at all times and follow instructions during the visit. I fully understand to where and at what time my young person is to be returning from the visit and that I am responsible for the collection of my young person from this point.

I agree to the participant receiving medication as instructed above. I also agree to them receiving any emergency dental, medical or surgical treatment, including anaesthetic or blood transfusion, as considered necessary by the medical authorities if it has not been possible to be contacted. (Please delete and initial any of the above you do not wish to give consent to). 

The information I have provided in this form is accurate at the time of signing and I have not knowingly withheld any information regarding physical fitness, medical issues or any other anxieties or pre-existing conditions. I agree to inform the visit leader as soon as possible of any changes between now and the start of the visit. In line with data protection guidelines, the information contained on this form will be kept with the visit leader (this includes taking the information out of the country where necessary) and the designated link person at the establishment for the duration of the visit for emergency purposes.

Name of Parent/Guardian/Carer:  

Signature:

Relationship to Participant:

Date: