EmailMeForm
Residential Visit Consent & Medical Information
This form must be signed by the parent/guardian/carer (unless the participant is over 16 years of age and living independently, in which
case they should complete and sign themselves). Please return to the Visit Leader in advance of departure.
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
*
Please select
Bronze
Silver
Gold
Which School
*
Please select
Campsmount
Ridgewood
McAuley
Date of Birth
*
DD
/
MM
/
YYYY
Gender
*
Please select
Male
Female
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
*
Please select
Yes
No
Is the participant recovering from an accident
*
Please select
Yes
No
Has this involved any broken limb or injury of any kind?
Does the participant have epilepsy
*
Please select
Yes
No
This includes convulsions, seizures or absenting of any kind?
Does the participant have any specific anxieties?
*
Please select
Yes
No
Does the participant suffer from travel sickness?
*
Please select
Yes
No
Is the participant diabetic?
*
Please select
Yes
No
Is the participant asthmatic?
*
Please select
Yes
No
Does the participant have any type of heart condition?
*
Please select
Yes
No
Does the participant have any Allergies ?
*
Please select
Yes
No
Is there any additional medical history we need to know
*
Please select
Yes
No
Including behavioural, learning difficulties or other conditions
Does the participant have any night time tendencies
*
Please select
Yes
No
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
*
Please select
Yes
No
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?
*
Please select
Yes
No
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