Wilmslow High School Educational Visits – Form VIS 4

Year 7Norcliffe

PARENT / GUARDIAN CONSENT FOR AN EDUCATIONAL VISIT

Student’s Name: ______Tutor Group:______

Student’s mobile phone number (for emergencies only): ______

It is proposed to organise the visit as indicated below:

Details of visit to: Alderley Edge Wizard Walk

Date: Friday 4th July, 9.00am – 3.00pm

I agree to ______(name of student) taking part in this visit

  1. Medical information about your child
  1. Does your child have any medical conditions? Yes/No
  • If ‘yes’, please give details:
  1. Will your child require any regular medication during the duration of this visit? Yes/No
  • If ‘yes’, please give details:

Name of medicine / Dose of medicine / Time when due
Example: Seretide inhaler / 2 puffs
  1. Does your child require any medication on an occasional basis? (such as inhalers; epi pen; antihistamine; etc)
  • If ‘yes’, please give details:

Name of medicine / Dose of medicine / Indication for use
Example: Piriton / 4mg tablet / For hay fever symptoms
  1. If medication is due during the school visit:
  • I request that my child carries their own medication and self-medicates as necessary on the visit: Yes/No
  • I request that my child is supervised when self-medicating: Yes/No
  1. Does your child have any allergies (including food and/or medication allergies)? Yes/No
  • If yes, please give details:
  1. Are there any recent illnesses or accidents of which the school should be aware? Yes/No
  • If ‘yes’, please give details:
  1. To the best of your knowledge, has your child been in contact with any contagious or infectious diseases or suffered from anything that may be contagious or infectious in the last four weeks? Yes/No
  • If ‘yes’, please give details:
  1. Emergency contacts during the duration of this visit:
  1. Name:______Work phone:______

Home: ______Mobile:______

Home address: ______

______

  1. Name:______Work phone:______

Home: ______Mobile:______

Home address: ______

______

  1. Name of family doctor: ______Telephone number: ______

Address: ______

______

Declaration

  • I have read the information provided. I agree to ______'s participation in the activities described and will ensure that he/she understands what is required of him/her during the visit.
  • I acknowledge the need for my son/daughter to behave responsibly throughout the visit and to follow staff instructions immediately and without question.
  • I acknowledge the need for my child to wear full Wilmslow High School PE kitas detailed throughout the visit.
  • I agree to my son/daughter receiving medication as instructed and any emergency dental, medical or surgical treatment, including anaesthetic or blood transfusion, as considered necessary by the medical authorities present.
  • I give permission for photographs to be taken and used to publicise the event.
  • Please tick here if your child receives free school meals and would like a packed lunch on the day:

Please return this signed form to the form tutor in an envelope labelled with your son’s/daughter’s name, form group and ‘Year 7walk VIS 4 form Commonwealth Week’

Students who do not return this signed VIS 4 form will not be permitted to take part in the walk and will complete appropriate work in school.

  • Signed: ______Date: ______
  • Full name (in capitals): ______

THIS FORM OR A COPY MUST BE TAKEN BY THE GROUP LEADER ON THE VISIT. A COPY SHOULD BE RETAINED BY THE SCHOOL EVC.