UKSA Residential Water Sports Week Medical Form
Must be completed by the parent/carer for students under 18 years old.

Whilst at UKSA your child will be taking part in adventurous activities, which may involve some personal risk. It is a legal requirement that before starting any activity you fully complete the following medical declaration. This information will help us to keep you or your child safe and deliver an effective training programme.

An electronic copy must be submitted on completion, and evidence of a hard copy, signed version of the form must be sent to UTC Portsmouth. This can be an email containing a photo/scan of a printed and signed copy, or the hard copy can be posted to UKSA Week, UTC Portsmouth, London Road, Portsmouth. PO2 9DU.
Email *
Student's Full Name *
Gender *
Height (cm) *
Weight (kg) *
Date Of Birth *
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Is your child able to COMFORTABLY swim 50m in light clothing? *
Does your child have any existing medical conditions? Please explain below: *
Do you consider your child to be differently abled? Please explain below: *
Does your child have any additional needs? Please explain below: *
Does your child have any dietary requirements? please explain below: *
Please insert next of kin details (name, relationship to applicant, address, telephone, email): *
Please insert second next of kin details (name, relationship to applicant, address, telephone, email): *
Name of your doctor: *
Address of your doctor's surgery: *
Phone number of your doctors surgery: *
Has your child been prescribed any medication in the last 3 months, or are you expecting to be prescribed any by August 2018? Please list below: *
In order for UKSA to ensure your child enjoys their time as much as possible, please tell us anything else about your needs that has not been covered in previous questions so that the week can be tailored where possible/appropriate. *
Date of most recent tetanus injection: *
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PARENT OR GUARDIAN: I declare that the information given above is accurate and true and I have not knowingly withheld any information (to knowingly withhold information could result in the termination of the child's training at UKSA without a refund. (Sign, print name and date): *
PARENT OR GUARDIAN: Consent for the use of photography or video. UKSA, UTCPortsmouth and supporting charities recognise the need to ensure the safety and welfare of children and young people taking part in boating. In accordance with our child protection policy we will not arrange for photographs, video or other images or young people to be taken without the consent of the parents/carers and children. Therefore we would like to ask your permission. UKSA, UTCPortsmouth and supporting charities will follow the guidance for the use of images, a copy of which is available from UKSA. UKSA, UTCPortsmouth and supporting charities will take all steps to ensure that images are used solely for the purposes for which they are intended i.e. coaching, marketing brochures, videos and website content. Names of children or groups are never placed alongside photos. Please delete as appropriate and print and sign below: I am happy / not happy for photos and video to be taken of my child for the purposes of coaching and marketing UKSA, UTCPortsmouth and supporting charities as organisations. *
I have sent a scan/picture/hard copy of this form with the parent/carer signature on *
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