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Nautical Training Corps

S2

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Consent, Agreement and Medical Information

Division, Region
Location:
Activity:
Valid from: / Date / To: / Date
Times: / Start time / - / Finish time

Once completed, this is a confidential document.

For more information, see Section ZZ2.4 of the Corps’ Safety Regulations.

Parental Consent and Agreement and Adult Agreement (please complete and tick as necessary)
Participant’s Name: _ _ Date of Birth: _ /_ /_ _
[ ] (parents of Corps members aged under 18 years old) I give my full consent for my child (as named above) to take part in the activities detailed above. I have received information about this activity, and my child and I know what to expect from the activity, and what is expected of us.
[ ] (adults) I have received information about this activity, and I know what to expect from the trip, and what is expected of me.
I understand that, while the Corps' Officers, Instructors and Helpers, in charge of the party, will take all reasonable care of all participants in their charge, the volunteerscannot be held responsible for any loss, damage, or injury suffered by members of the group in travelling to or from, or taking part in any of the activities, if the Corps' regulations have been implemented and followed.
Medical Information (please complete accurately and delete underlined appropriately) / I/ my child has or had the following (please tick)
Asthma or Bronchitus [ ]
Heart Condition [ ]
Fits, fainting or blackouts [ ]
Severe headaches [ ]
Diabetes [ ]
Allergies to any drugs [ ]
Any other allergies (inc. food) [ ]
Any recent contact with contagious diseases and infections [ ]
I have written details of the above on the reverse, or a separate sheet (which is securely attached, and I have ticked below).
Separate sheet attached [ ]
I/ my child has no illness or disability/ the following illness or disability:

Continue on reverse if necessary

Which necessitates the following treatment:
Continue on reverse if necessary
I/ my child has been given the following instructions to follow in an emergency:
Continue on reverse if necessary
I consent to my child receiving emergency medical treatment during the activity detailed on this form, or at a hospital at anytime following an accident.
Next of Kin details (accurate for duration of activity) / Personal Doctor Details
Name: _ _
Address: _ _
_ _
_ _
Post Code: _ _ / Name: _ _
Address: _ _
_ _
_ _
Post Code: _ _
Landline Telephone _ _ / Landline Telephone _ _
Mobile Telephone _ _ / Last Tetanus Immunisation _ _
School Details / School: _ _ Class: _ _
I undertake to inform the Nautical Training Corps immediately if any of the details given on this form change during the period of this form’s validity.
Parental or Adult Signature
I confirm that all of the details on this form are correct to the best of my knowledge.
(parent signature for under 18s)
Signed: _ _ (adult’s signature)
Print Name: _ _

Version 2.0, Decmber 2010 Form designed by Adventure Activities Director, Nautical Training Corps