Y5 Hooke Court
Please complete the form below by Friday 17th May. If there is an issue relating to your child that you wish to discuss individually, please contact your child's class teacher or a member of the Year 5 team.
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Child's Full Name *
Class *
Date of Birth *
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DD
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YYYY
Home Address *
Parent/Carers Names *
Contact Numbers - Please give the phone numbers at which you can be contacted during the visit in an emergency (e.g. home/mobile/work). Please also state who the number belongs to and any preferred time of day to use it (e.g. Mum - 079103575618 - All day) *
Please give the best phone number to contact during the night. If this has already been listed above, please enter again here. *
Does your child have any medical conditions? (e.g. asthma, hayfever, epilepsy) *
If yes, please state the condition and any details regarding symptoms/treatment.
Does your child take any medication (or will need to during the trip)? *
If yes, please list any medication your child currently takes/will need to take on the trip (dosage and frequency)
How is the medication administered?
Will your child need to take travel sickness medication during the journey there and back? *
If yes, please list any sickness medication your child will need to take on the trip (dosage and frequency)
Does your child have any allergies? *
If yes, please list any allergies your child has.
Does your child have any dietary requirements? *
If yes, please list any dietary requirements your child has.
Please give details of any illness, injury or disability that might possibly affect you child's performance/safety during the weekend. *
Does your child suffer from enuresis (bed wetting)? *
If yes or maybe, please give details.
How confident is your child in the water? *
Has your child experienced homesickness before? *
If yes, please give details.
Is there any other information you feel we should know about your child that may help us during this trip? (e.g. periods, strategies that help your child, fear of heights)
Name of child's doctor *
Address of surgery *
Phone number of surgery *
Do you give permission for your child to have their photograph taken and posted on Instagram during the trip? *
Do you give permission for your child to have their photograph taken and posted in the Newsletter? *
If you are happy for staff to administer the appropriate age-specific dose of sugar-free ‘Calpol’ if they feel it is necessary, please select 'Yes' below.  By selecting 'Yes' you are confirming your child has previously been administered sugar-free ‘Calpol’ and has never suffered any adverse effect. *
Please tick 'Yes' below to indicate that: You are aware of the nature of the proposed visit to Hooke Court and the activities offered and that you consent to your child named participating. You undertake to inform us of any change in your child’s fitness prior to the date of your departure. You have ensured that your child understands that it is important for their safety and for the safety of others that any rules and instructions given by staff are obeyed. *
Please tick 'Yes' below to give your consent for school and Hooke Court staff to: Allow your child to take any medication specified above; Call a registered medical or dental practitioner to prescribe treatment or  medication if required; Administer emergency first aid treatment as necessary. *
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