HEALTH FORM AND DECLARATION FOR FRYLANDS BIG WEEKEND 2017
(Please write clearly and complete all sections on both sides of this form)
Group:- / Group Leader:-Title_____ Surname______Forename(s)______
Home Address ______
______
Post Code ______Country ______
Date of Birth ______Age ____ NHS Number ______
In an emergency please contact:-
Title :-____Surname:- ______
Forename:- ______
Relationship:- ______
Address:- ______
______
______
Post Code ______Country ______
Daytime tel:- ______
Evening tel:- ______
Mobile or other no.______
(please include national/international dialling code) / Participants Family Doctor:-
Name:- ______
Address:- ______
______
______
Post Code ______Country______
Telephone:- ______
(please include national/international dialling code)
If receiving Hospital treatment
Name of Hospital:-______
Hospital tel:- ______
Patients Hospital No:- ______
Consultant:-______
Emergency Permission
I give permission for my child to receive any necessary medical or first aid treatment, for any illness or injury.
I also give my permission for any leader to give consent for any necessary hospital/medical treatment provided reasonable attempts have been made to contact me.
Signed:- ______
Print Name:- ______
Relationship:- ______
Date:- ______/ Allergies
Is the participant allergic to ANYTHING (e.g. medicines, food, elastoplast) ?
YES/NO
Please give details:-
______
______
______
______
______
Medical History
Does the participant have any Medical History e.g. any operations, heart problems, epilepsy, diabetes or asthma? YES/NO
List overleaf anything you think significant. / Medication
Does the participant take any medication?
YES/NO
List overleaf
Participants Own Medication List
Please list ALL medication, regular or occasional, with dosage and storage instructions. It is ESSENTIAL that the participant brings enough regular medication for the duration of the camp, in their original containers, clearly labelled with name, product and dosage details.
Full generic and brand name Dosage details(quantity, times of day, storage etc)
______
______
Participants under 16 should give their medicine to their leader for safe keeping, however inhalers etc should be kept with the individual, with a spare being given to the leader.
Significant Medical History
Please indicate below any Medical History we should know about, particularly any current treatment or any treatment, surgery or investigations within the last six months. Please include hospital and surgeon details if appropriate. Has the participant been in contact with any contagious disease within the last two weeks or travelled from a country where any contagious diseases are endemic.
______
______
______
______Date of last Tetanus vaccine:- ______
Please continue on additional paper if required
Medication Available On Site
The following are available as appropriate, please indicate if any should NOT be given, and include a brief explanation why.
Dosages will be in accordance with the recognised medical recommendation.
Paracetamol (tablets and elixir)
Ibuprofen (tablets and elixir)
Chlorphiramine e.g. Piriton (tablets and medicine) – for allergies
Antacid e.g. Gaviscon, Rennies (tablets and medicine)
Simple Linctus (cough mixture)
1% Hydrocortisone cream (not on faces)
Insect bite cream e.g. Waspeze, Anthisan
Calamine Lotion
Loperamide e.g. imodium
I give permission for the above to be given at the appropriate dose
Signed:- ______Print:- ______Date:-______
Participants are expected to supply their own sun creams/blocks/moisturisers. We request that participants who wear glasses bring a spare pair if possible; participants who wear contact lenses must bring sufficient supplies.
We’re A Knockout Health Declaration
· Any participant under the age of 18 will not be allowed to take part in the We’re a Knockout competition without the consent and counter signature of a parent or guardian.
· Prior to commencing the We’re a Knockout games, every competitor must carry out a warm up routine under the guidance to the We’re a Knockout team. They must be present at the safety briefing and follow all instructions or be removed from the games.
· If you are suffering from any known heart or respiratory problems you must not participate in any of the activities. If at any time you feel faint or breathless during the activities you must stop immediately.
· You must be in good health and physically fit at the time of the games in order to be an active participant.
Signed:- ______Print:- ______Date:-______
Information detailed on this document will be held in accordance with UK law regarding Data Protection, with access being granted to authorised staff only.