Emergency Medical Details & Education Visit Consent Form

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This confirms your agreement for the school to initiate appropriate medical treatment in the event of an
emergency. This form will enable your child to attend day visits. In some cases, a separate consent slip for each visit will not be required once you fill in this form, but we will still notify you of any trips taking place.

GDPR Statement
By signing this form, I confirm my agreement to School / Establishment processing my / my child’s personal data for the purpose of supervising and supporting my child at school and on an educational visits. We do this to meet our professional responsibilities to look after you / your child. This data may be shared with outdoor providers, doctors and other professionals to help us keep you / your child safe.
This data will be retained for the time your child attends the school, other than in the event of an accident / incident, in line with SCC / School Retention Policy.
You have some legal rights in respect of the personal information we collect from you.
Please see our website Data Protection Policy for further details: www.bitterneceprimary.net

Your child's name? *

Date of birth? *

YYYY

Next of Kin? *

Contact details for next of kin? *

Name and Address of Doctor? *

Telephone Number of Doctor / Surgery? *

Has the participant had or have any of the following? If you have ticked to confirm any conditions, please give specific details below. *

Asthma or bronchitis

Heart condition

Fits, fainting or blackouts

Severe headaches

Diabetes

Allergies to any know medication

Other allergies (material, food, animal, plasters)

Other illness, disability or special needs

Travel sickness or sleepwalking

Regular medication

Toileting Needs

Support and/or treatment for mental health from their counsellor or Doctor?

Medical or surgical treatment of any kind from their Doctor or hospital?

Has the participant been given specific medical advice to follow in emergencies?

No Medical Condition

Required

If the answer to any of these questions above is yes, please give further details: *

If it is considered necessary, do you consent to mild painkillers (Paracetamol) being administered? *

Yes

If it is considered necessary and your child has a confirmed diagnosis of asthma, do you consent to emergency Ventolin being administered? *

Yes

N/A

If it is considered necessary, and your child has a confirmed diagnosis of anaphylaxis, do you consent to an emergency adrenaline pen being administered? *

Yes

N/A

Has the participant received vaccination against Tetanus in the last 10 years? *

Yes

Not sure?

In the event of illness or accident, I consent to any necessary medical treatment, which might include the use of anaesthetics. In the event of any change to these details, illness or medical treatment occurring after the return of this form, I will undertake to inform the school of any changes. Please state your name below. *

Consent for School Trips - I confirm that I have parental responsibility for the child detailed above. He / she is in good health and I accept that, by their nature, adventure activities and educational visits may involve some level of risk which cannot be fully eliminated. I consent to my child taking part in ALL activities set out in the school's Educational Visit Policy?. *

Yes

Required

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