Medical and Consent Information 5th/9th Chelmsford Scouts

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This form will be copied to the Event Organisers and will be used by the First Aid team and any necessary professional medical staff. This information will be held in confidence and will be destroyed two months after the completion of the event in accordance with GDPR guidelines. This form must be completed for each attendee (youth member, young leader or adult). Those over the age of 18 may complete and sign the form for themselves

Name of Event / Activity

0Date(s) of Event or Activity *

YYYY

Full Name *

Date of Birth. *

YYYY

Home Address (including postcode) *

Contact name and phone number *

Contact E Mail *

Emergency contact name and phone number *

Practise name, address, postcode and phone number of family doctor *

Have you been in contact with any contagious or infectious disease in the last 3 weeks? *

Yes

L Is answer was Yes to above, please advise which illness

Have you suffered from any recent illness? *

Yes

If answer was Yes to above, please advise which illness

Any allergy or sensitivity to the following:? *

YES

Aspirin

Bee or Wasp Sting

Nuts

Paracetamol

Penicillin

Plasters

Other (please detail below)

If Yes, is an Epipen required?

If answer was 'Other' to above, please advise details below /

Any current medical conditions *

Any current medications being taken including dosage *

Any Other Information that would be helpful to us ?

I understand that photographs or video may be taken during the event for promotional purposes. I confirm below whether I can be photographed or filmed for this purpose *

Yes

Required

By entering my full name below, I understand that all activities will be run in accordance with the Safety Policies of the Scout Association and will therefore be run by appropriately qualified personnel as required *

By entering my full name below, I confirm that all information provided on this form is correct and up to date to the best of my knowledge *

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This form was created inside of 5th-9thchelmsford.org.uk.