WhitbyResidential Visit
MEDICAL & DIETARY INFORMATION SHEET
To be completed by parents or guardians on behalf of the child attending and returned to Mr. Tuxworth by Thursday 30th June2016.
DATE OF VISIT: 11th July to 15thJuly 2016
Name (child attending) ______
Address______
______Post Code ______
Telephone Contact Numbers
(Please provide alternative numbers such as home, work etc. and more than one contact if possible.)
Contact’s Name / Relationship to Child(eg. mother) / Location
(eg. home, work, mobile) / Number
If your child is registered at the Spinney Surgery in St. Ives, tick here:
If it’s elsewhere, please give details below:
Doctor ______
Address______
______Post Code ______
Telephone No. (Daytime) ______(Evening) ______
1.Does your child have a rare blood group? YES/NO
If yes, please state which group ______
2. Is your child allergic to any medicines, e.g. Penicillin? YES/NO
If yes, please give details ______
______
3. For children to receive medication administered by school staff whilst they are away we will require a consent form to be signed and details of the medication to be provided. Some parents may already know that their child will be requiring medication whilst they are away so if that is the case we will ask you to complete a separate form shortly. If, nearer the time, you find your child will be requiring medication of which we’re not already aware, please let Mr. Tuxworth know.
Has your child already been prescribed medication to take during their residential visit? YES/NO
Has your child had a Tetanus injection? Yes/No When? ______
Is there any other information concerning your child’s health that you feel we should know about? I.e. sleepwalking, asthma, epilepsy, hay fever, diabetes, bed wetting etc. Please feel free to talk to a member of staff if you’d rather not record it on this form.
______
DIETARY INFORMATION
To ensure your child receives the food they require, please complete the following:
1. Does your child require vegetarian or vegan meals? YES/NO
If yes, please circle choice: Vegetarian or Vegan
2. Is your child allergic to food items? For example nuts, milk, flour, etc. YES/NO
If yes, please list below:
- ______
- ______
3. Any other details we may need regarding catering for your child’s needs? YES/NO
If yes, please explain below (or attach a separate sheet?)
______
INSURANCE ARRANGEMENTS
I understand that ( my son / daughter ) will participate in a programme of activities which has been carefully planned and risk-assessedby the school.
I understand that the insurance of Cambridgeshire County Council covers all legal liability to all students on courses. Personal Insurance is provided for all Cambridgeshire County Schools on receipt of the first stage payment.
Signed ______Parent/Guardian Date ______
CHILD WELFARE
The welfare of the children is paramount whilst away on residential visits. We will therefore be insisting that the children behave in an acceptable and safe manner at all times and that they follow all instructions given by members of staff. If we feel that the behaviour of any child in any way poses a risk to the safety of themselves or others, we will have to ask the parents or guardians of the child concerned to collect him or her from the Old School House in Robin Hood’s Bay where we will be staying throughout the visit.
Please sign below to show that you agree to collect or make arrangements for your child to be collected if we feel that their behaviour poses a risk to themselves or others whilst away at the camp. Please be assured that this option would only be chosen as a very last resort.
Signed ______Parent/Guardian Date ______