A Uniformed Youth Inclusion Programme
Parent’s Consent &
Confidential Candidate Medical Form
Information provided is in the strictest confidence and for CT use only
Emergency Contacts: Captain Simon Dean (mobile - 07770 570012)
Lieutenant Jo Morris (mobile - 07971 139605)
Candidate’s details
Name: ______Date of Birth: ______
(Please print)
Address: ______Tel No: ______
______Mobile No: ______
______
______
Height: ______Weight: ______Chest:______Waist:______Shoe size:______
Ethnic Group: ______Gender: ______
Swimming Ability (E.g. Weak/Acceptable/Strong): ______
Next of Kin / Emergency Contact Details
Next of Kin: ______Relationship: ______
Address: ______Tel Numbers:
______(daytime) ______
______(evening) ______
______(mobile) ______
Medical Details
Does your son/daughter/ward suffer from any allergies? If so please record them below.
______
______
Is your son/daughter/ward taking any regular medication? If so please list below.
______
______
Is your son/daughter/ward allergic to any medication? If so please list below.
______
______
Does your son/daughter/ward have any dietary restrictions or special food needs? If so please list below.
______
______
To the best of your knowledge, has your son/daughter/ward been in contact with any contagious or infectious diseases or suffered from anything in the last 3 months? Please give details
______
______
Does your son/daughter/ward suffer from anything of which you think we should be aware?
______
______
Is there any other physical or psychological history that may affect your son/daughter/ward in specific activities? (If you would feel more comfortable discussing any area privately with us, please put ‘to be discussed’ and we will contact you)
______
______
Does your son/daughter/ward suffer from any of the following? Delete as appropriate
Asthma YES/NO
Other Chest and Heart Conditions YES/NO
(Other than mild chest infections, a chest or heart condition may be significant; this includes any history of bronchitis or wheezing)
Epilepsy YES/NO
Any loss of consciousness or blackout YES/NO
(This includes any history of fainting episodes)
Ear or sinus problems YES/NO
Severe headaches YES/NO
Any other major illness or injury (Specify)…………………………………...... …...... YES/NO
Any conditions requiring regular prescribed medication YES/NO (Specify)…………………………………………………………………………………………………………………
Any condition requiring regular care or visits to a doctor or hospital specialist YES/NO (Specify)………………………………………………………………………………………………………………...
Any other disability (Specify)………………………………………………………………………………….. YES/NO
Has your son/daughter/ward received a tetanus injection in the last 5 years? YES/NO
Details of candidate’s GP
Name: ______Telephone Number:______
Address: ______
______
______
Please note that the adult in charge after due consultation with a First Aider or other member of the medical team, has the authority to refer the candidate to hospital for treatment in accordance with the injury.
In case of emergency, I give my consent to authorise all medical and/or surgical treatment for my child/ward during Challenger Troop activities.
Signature: ______Date: ______
(Person with parental responsibility for candidates under 18 years of age)
PARENT/GUARDIAN CONSENT & DECLARATION – IMPORTANT PLEASE READ
Delete as appropriate
I give my full consent to the participation of my son/daughter/ward in the
Challenger Troop Programme and agree to fully support them and CT with my YES/NO
son/daughter/ward’s development.
I give my consent to CT taking video/photographs for the purposes of YES/NO
programme, marketing or school reports. Please state if this is not the case.
I acknowledge the need for my son/daughter/ward’s obedience and responsible
behaviour. I understand that if my son/daughter/ward breaks the rules agreed with YES/NO
them, then they may be removed from the programme.
I agree that in the event of my son/daughter/ward causing deliberate damage to
Challenger Troop equipment, then I may be charged accordingly in order to YES/NO
repair / replace the damaged items. This will be capped at £100.
I agree to inform the school and/or Challenger Troop if any of my
son/daughter/ward’s medical circumstances change in the time between signing YES/NO
this form and the end of the programme.
I understand the extent and limitations of the insurance provided. YES/NO
I understand Challenger Troop has no affiliation or association with the Ministry of Defence (MOD), the Reserve Forces & Cadets Association (RFCA) or any of their related defence organisations.
Supervised under qualified staff the following activities may possibly include:
Kayaking – Canoeing – Rafting – Swimming – Outdoor Exercise including travelling in Vehicles and Foot patrolling - Mountain Biking –Physical Training in Gymnasium or out of doors – Command Tasks – Tug of War – Laser Tag – Survival
Signature: ______Date: ______
(Person with parental responsibility for candidates under 18 years of age)
Name: ______(Please Print)
Challenger Troop, Challenger House, TA Centre, St John’s Rd, Tunbridge Wells, Kent, TN4 9UU. Tel: 01892 543150