This section (both pages) is to be completed by the Parent or Guardian of the young person named below.
Please answer the following questions as fully as possible. As in the event of your child requiring emergency treatment, it will help the medical authorities in deciding which is the most appropriate treatment to give.
(Please complete in BLOCK CAPITALS)

Surname ...................................................

Forenames ..................................................

Date of Birth ..............................................

National Health Service Number .............................

He may bathe under careful Supervision. Yes • No •

Date of last Tetanus injection ............................

Parent/Guardians Address During the Camp/Holiday
...........................................................................

...........................................................................

Telephone .......................................

Family Doctors Name and Address

Telephone ............................


I hereby give permission for my child to attend the aforementioned Camp/Holiday.

If it becomes necessary for my child to receive medical treatment and I cannot be contacted by telephone or any other means to authorise this, I hereby give my general consent to any necessary medical treatment and authorise the Camp/Holiday leader named above (or in their absence one of the assistant camp/holiday leaders named overleaf), to sign any document required by the hospital authorities.

I will inform the Camp/Holiday Leader if any of the information given on this form changes before the event takes place.

Name of Parent/Guardian Relationship to Young Person

Signature.......................................

Date ........................................

The Camp/Holiday Leader (or in their absence one of the assistant Camp/Holiday leaders named above) may administer the appropriate minor treatment/precautions (as listed overleaf) if required.

Headache ..........................................

Stomach Upset ..........................................

Cuts & Grazes ..........................................

Colds etc. ..........................................

Other Specific Ailments Please continue below if required.
In the space below please give details of the following:-

1. Any Known Infectious Diseases with which Your Child (named overleaf) has been in contact within the last three weeks (e.g. Chicken Pox, Diphtheria, Measles, Mumps, Rubella, Whooping Cough etc.)

2. Any Known Allergies/Sensitivities/Disabilities and details of any known precautions or remedies
(e.g. Penicillin, Food Colourings, Travel Sickness, Bed-wetting, Asthma etc.)

3. Details of any Medicines/Diets/Treatments currently being Taken/Followed (including dosage details) & the Specialist and Hospital concerned if appropriate (please include any non prescription preparations, such as cough sweets , herbal medicines).
(If He has to take any Medicine's, the bottle(s), jar(s) or other items should be clearly labelled with their) (name and the exact dosages, and should be handed to the Camp Leader/First Aider before departure. )

Please continue on a separate sheet if required (Remember to include your child(s) name on any separate sheets and attach them securely to this form)