Kingswood Residential Centre
CONSENT FORM & MEDICAL QUESTIONNAIRE
A journey to Kingswood Residential Centre (Isle of Wight)
OnWednesday 7th March – Friday 9th March
I wish my son/daughter ______Class ______
Date of Birth:
to be allowed to take part in the above-mentioned school journey and, having read the information sheet, agree to his/her taking part in any or all of the activities described.
I have ensured that my child understands that it is important for his/her safety and for the safety of the group that any rules and any instructions given by the staff in charge are obeyed.
I understand that, while the school staff and helpers in charge of the party will take all reasonable care of the young people, unless they are negligent they cannot be held responsible for any loss, damage or injury suffered by my son or daughter arising during or out of the journey.
(Note: School Journey Insurance is automatically arranged with Chartis Insurance, through West Sussex County Council, for participating establishments.)
Please advise the establishment of any changes to the medical information already provided.
PARENT/CARER NAME AND INITIALS
HOME ADDRESS
TELEPHONE NO.
NAME AND ADDRESS OF
FAMILY DOCTOR______
______TELEPHONE NO.
(Continued Overleaf)
Has your child had any of the following:-
Asthma or BronchitisYESNO
Heart conditionYESNO
Fits, fainting or blackoutsYESNO
Severe headachesYESNO
DiabetesYESNO
Allergies to any known drugs or medicationYESNO
Any other allergies or special dietary requirements
e.g. material, food, insect bites etc.*YESNO
Other illness or disabilityYESNO
Any recent contact with contagious diseases and infectionsYESNO
If the answer to any of these questions is YES please give details give the details here
*Only allergies to food diagnosed by a doctor (not dislikes) will be tolerated
Has your child received vaccination against
Tetanus in the last ten years?YESNO
Is your child receiving medical treatment of any
kind from either your Family Doctor or Hospital?YESNO
Has your child been given specific medical advice
to follow in emergencies?YESNO
If the answer to either of these questions is YES please give the details here:- (including dosage of any medicines/tablets)
I agree to hand any medicines in their original containers with their Patient Information Leaflet in to school on the morning of the residential trip.
I agree that, should it be required, the school can administer paracetamol or antihistamine to my child.
I agree that, should it be required, the school has the authority to administer emergency first aid and if necessary call an ambulance for my child.
SIGNED Parent/Guardian
DATE