EmailMe Form - Residential Visit Consent & Medical Information

Candiates Forname *

Candidates Surname *

Candidates eDofE ID number

Your son / daughter will need to log onto eDofE to give you this

Parents Email *

Level of Award *

Which School *

Date of Birth *

DD / MM / YYYY

Gender *

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code

Emergency Contact Details of Parent/Carer/Guardan

Name *

Relationship: *

Home Phone *

Mobile *

Work Phone

Address 2

Street Address City State / Province / Region Postal / Zip Code

Address 2 is if you live at a different address to you son / daughter

Medical/Behaviour Information (Please answer Yes or No to each statement by deleting as appropriate.)

Has the participant had any serious illness in the last 3 months *

Is the participant recovering from an accident *

Has this involved any broken limb or injury of any kind?

Does the participant have epilepsy *

This includes convulsions, seizures or absenting of any kind?

Does the participant have any specific anxieties? *

Does the participant suffer from travel sickness? *

Is the participant diabetic? *

Is the participant asthmatic? *

Does the participant have any type of heart condition? *

Does the participant have any Allergies ? *

Is there any additional medical history we need to know *

Including behavioural, learning difficulties or other conditions

Does the participant have any night time tendencies *

such as sleepwalking, bed-wetting, etc?

If you have answered ‘Yes’ for any of the above, explain below

When did the participant last have a tetanus injection?

DD / MM / YYYY

If not known tick here

Not known

Is the participant physically and medically fit *

Doctors Information

Name of Doctor *

Phone number *

Dr Address *

Street Address City State / Province / Region Postal / Zip Code

Medical Treatment Whilst Participating in the Visit (Please answer Yes or No/Some)

Participants sometimes need treatment for minor ailments *

Yes

No

Some

E.G. headaches, insect bites, sunburn, cuts/grazes etc. If deemed necessary, do you give permission for establishment staff to treat such ailments with the following ‘over the counter’ products: paracetamol, Ibuprofen, antiseptic cream, calamine lotion, antiseptic wipes, insect bite antihistamine, sun cream, plasters?

If No to the above, please state below

Paracetamol

Ibuprofen

Antiseptic Cream

Calamine Lotion

Antiseptic Wipes

Insect bite antihistamine

Sun Cream

Plaster

Which of the products listed above you do not wish the participant to be given (or if other alternatives are acceptable or preferred instead):

Alternative medication that can be given

Prescribed Medication

Is the participant taking any prescribed medication? *

If you answered ‘Yes’ to the above question please read and complete the section below:

It is important that this child is accompanied by any medication necessary, and that leaders are fully informed. Please make sure that there is sufficient medication, and that it is clearly labelled.

Medication

Name of Medication
Dosage
Time & Frequency
Method od Adminstration

Consent declaration *

Yes

No

I give my consent for a member of staff to administer the above medication which I will give to the Visit Leader before the visit, with clear labels and instructions. I understand that the staff on the visit are not qualified medical practitioners, but that they will take reasonable care in the administration of the medication.

Participant self administration of medication *

Yes

No

I give my consent for this participant to self-administer the above medication.

Dietary Information

Food allergies or dietary requirements eg vegetarian *

Consent

I have received full information about the visit, understand the nature of the visit and consent to the participant engaging in all of the activities described. I understand that the visit may be changed by the Visit Leader due to weather or other reasons. I understand and accept that there is some level of risk in every activity, but that all reasonable measures will be taken to minimize the risks involved and I will ensure that the participant understands that they must behave responsibly at all times and follow instructions during the visit. I fully understand to where and at what time my young person is to be returning from the visit and that I am responsible for the collection of my young person from this point. I am aware of the Insurance Cover in place for this visit. The policy details can be found on the school website under the information, policies and documents section.

I agree to the participant receiving medication as instructed above and that they are not traveling against the advice of a qualified medical practitioner. I also agree to them receiving any emergency dental, medical or surgical treatment, including anaesthetic or blood transfusion, as considered necessary by the medical authorities if it has not been possible to be contacted.

The information I have provided in this form is accurate at the time of signing and I have not knowingly withheld any information regarding physical fitness, medical issues or any other anxieties or pre-existing conditions. I agree to inform the visit leader as soon as possible of any changes between now and the start of the visit. In line with data protection guidelines, the information contained on this form will be kept with the visit leader (this includes taking the information out of the country where necessary) and the designated link person at the establishment for the duration of the visit for emergency purposes.

Types of treatment you do not wish to give consent to

Emergency dental

Surgical treatment

Anaesthetic

Blood transfusion

Please tick all those that are applicable, leave all blank if non apply.

Name of Parent/Guardian/Carer: *

Relationship to Participant *

Signature *

Clear

You can use the Mouse/digital pen/finger to sign dependant on the device you are using

Date *

DD / MM / YYYY