National Youth Pilgrimage Whithorn
Sunday 18th Sept 2016
Parental/Guardian Consent & Emergency Information Form
For young people P7- young adult. (bring a packed lunch)
Young person’s details:
Full name:
Address:
Email:
Home telephone number______
Date of birth: ______
Relationship to the child named above: ______
Medical information about the young person:
Please give details of any conditions requiring medical treatment including medication, for example, inhalers, anti-epileptics or insulin.
______
Please outline any special dietary requirements of the young person (including allergies, for example, nuts) and the type of pain/flu medication the child may be given if necessary.
______
Please outline any fears/phobias the young person has. This information will assist the adult helpers to assist the young person should any difficulties arise.
______
Is the young person allergic to any medication, for example, penicillin? Please give details.
______
When did the young person last have a tetanus injection? ______
Is there any other relevant information/specific needs that need to be known by the organiser (for example, travel sickness/mobility)?
______
To the best of your knowledge, has the young person been in contact with any contagious or infectious diseases or suffered from anything in the last few weeks that may be contagious? Please give details.
______
I will inform the Diocesan Youth Officer, Denise Roberts, (07717580326)as soon as possible of any changes in the medical or other circumstances between now and the commencement of the journey.
Emergency contact:
Name, address and land and mobile telephone numbers:
Relationship to the child:
Family doctor:
Name, address and telephone:
Parental/Guardian consent and declaration:
I am willing to allow the above named child to take part in the above activity. I understand that group/activity photographs/video may be taken during the events, in line with the Church’s policy. Photographs/videos will be displayed on church notice boards, letters and newsletters, diocesan facebook page, and websites I give my consent to this.
I understand that in the event of an illness or accident every effort will be made by the event leader or their assistants to contact me. If, for whatever reason, this is not possible I agree to the named child above 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 understand that during this event the child named above will be in the charge and under the supervision of the group leaders (& Diocesan Youth Officer), and that whilst the leaders will take all reasonable care of the named child above they cannot be held responsible for any loss, damage, or injury suffered by him/her arising during or out of the event. The leaders cannot be held responsible for any loss or damage of personal effects.
Signed:
Name in full: Date:
Youth Officer for Argyll & Isles: Denise Roberts
Telephone: 07717580326