Jonginenge - Medical Information and Indemnity Form for Schools
THIS FORM IS A CONSENT TO PARTICIPATE, RELEASE, WAIVER OF LIABILITY AND INDEMNITY AGREEMENT.        (All questions need to be answered. Insert "not applicable" in any fields for which you do not have information)       email:        cell: 0833052590             CC. no: 2005/034556/23
Sign in to Google to save your progress. Learn more
School Name: *
Class *
Name of Child *
Surname of Child *
Date of Birth *
Home Address: *
Medical Aid (If yes, fill in the details below as requested) *
Medical Aid Scheme: *
Medical Aid Number: *
Name and Surname of Principal Member: *
Doctor's Name: *
Doctor's contact number: *
Allergies or Medication (Any Medical Conditions we should be informed about?)                                                                                            Please note that those children who are allergic to bees must bring along an EpiPen or an antihistimine. *
Mom's name: *
Mom's contact details: *
Mom's email address *
Dad's name: *
Dad's contact details: *
Dad's email address *
Emergency Contact Name and Surname (In case of an emergency, if we cannot get hold of any parent, who would you prefer us to contact?) *
Emergency Contact number: *
Name and Surname of Parent/Guardian giving consent: *
Have you had any history of fever in the last 14 days? *
Have you had any respiratory illness such as cough or difficulty breathing in the last 14 days? *
In the past 14 days, have you or nay household member had any contact with a known COVID-19 patient? *
Have you or any household member traveled to an international area of suspected community spread in the last 14 days? *
Have your or any household member had history of exposure to COVID-19 biologic material? *
DO YOU GRANT PERMISSION FOR YOUR CHILD TO ATTEND THE ENVIRONMENTAL EDUCATION EXCURSION WITH JONGINGENGE?   By selecting YES, you agree that you are aware that there are risks, hazards and uncertainties connected with their participation in the excursion, and that you understand that precautions will be taken to ensure the safety of your child at all times. You believe that Jonginenge will exercise due care to ensure the safety of your child. You therefore will not hold Jonginenge or the facilitators in charge, responsible for any injury incurred by your child. *
Date that this Indemnity Form was completed. *
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy