EXPRESSION 2016

PARENTAL CONSENT FORM

1. EVENT OR ACTIVITY
YOUTH RETREAT

to be filled in by ALL participants under 18

DATES
18TH - 21ST FEBRUARY 2016

2. CONSENT
I agree for
D.O.B
(Please write full name)
I agree for his/her participation in the above activity
I understand that group/activity photos may be taken during the event, in line with the churches policy
I acknowledge the need for my child to act responsibly and in accordance with the code of conduct
3. TRANSPORT
I will make the necessary arrangements for the dropping off and collection of my child to the agreed place
which is. ST JOSEPHS CATHOLIC SECONDARY SCHOOL, CHURCH ROAD, LAVERSTOCK, SALISBURY SP1 1QY

4. MEDICAL INFORMATION
1. Any conditions requiring medical treatment including medication e.g Inhalers, insulin, epi pens
YES

No

please give details of medication and occasion for use

Please outline any special dietary requirements inc. allergies ie nuts also any type of pain relief that your child MAY
be given if nessesary. Please make clear if your child is allergic to any medication such as Penicillin

Date of Last Tetanus Injection

5. FEARS, PHOBIAS. TRAVEL SICKNESS & MOBILITY

Please let us know if there are any considerations or difficulties we should be aware of including
travel sickness or mobility issues

To the best of your knowledge has your

Son/daughter been in contact with anything contagious or infectious in the last few weeks
If Yes please give details

NO

I will contact the event leader as soon as possible in the event of any medical changes before the event commences
6. CONTACT INFORMATION
PARENTS
NAME

ADDRESS

MOBILE
HOME
EMAIL
ALTERNATIVE EMERGENCY CONTACT
NAME
ADDRESS

PHONE NUMBERS
DOCTORS CONTACT INFORMATION
NAME OF FAMILY DOCTOR
NAME & ADDRESS OF SURGERY

PHONE NUMBER

DECLARATION
In the event of an illness or accident every effort will be made by the event leader or their assistants to contact me. If for
whatever reason this is not possible I agree to my son/daughter receiving medication as instructed and any emergency
dental,medical, surgical treatment including anaesthetic or blood transfusion as considered necessary by medical Auth.
SIGNED
DATE
FULL NAME IN
CAPITALS