v5 mint green

ALSAGER SCHOOL Form (V5)

SCHOOL VISITS PARENTAL CONSENT FORM DETAILS OF JOURNEY Journey / Visit to: ________________________________________________________ From:

______________(Date/time) To: _______________(Date/time)

I agree to my son / daughter: ______________________ From Group: __________ Taking part in the above mentioned visit and, having read the information sheet, agree to his / her participation in any or all of the activities described. I acknowledge the need for obedience and responsible behaviour on his / her part.

MEDICAL INFORMATION Does your son / daughter suffer from any conditions requiring medical treatment?

If YES, please give brief details: __________________________________________________________________________ __ To the best of your knowledge, has your son / daughter been in contact with any contagious or infectious deiseases or suffered from anything in the last four weeks that may be or become contagious or infectious?

If YES, please give brief details: __________________________________________________________________________ __ Is your son / daughter allergic to any medication?

If YES, please specify: __________________________________________________________________________ __ Has your son / daughter received a tetanus injection in the last ten years? YES / NO Please outline any special dietary requirements of your child overleaf.

I undertake to inform the Co­Ordinator / Headteacher as soon as possible of any changes in the medical circumstances between the date signed and the commencement of the journey.

DECLARATION I agree to my son / daughter receiving emergency medical treatment, including anaesthetic, as considered necessary by the medical authorities present. I understand the school has taken out insurance cover on each child participating on the trip. I may be contacted by telephoning the following numbers: Work: _______________ Home: _______________ Mobile: _______________ My home address is:

__________________________________________________________________________ __ __________________________________________________________________________ __ PTO Name, address and telephone number of family Doctor: __________________________________________________________________________ __ __________________________________________________________________________ __

GROUP PASSPORT (Foreign Trips Only) Town and Country of Birth (Details as on Birth Certificate): __________________________________________________________________________ __

DATE OF BIRTH: ______________

Please use this space to inform the Trip Organiser/s of any additional Signed: _________________________ Date: _________________ information plus any special dietary requirements.

This form or a copy must be taken by the leader on the activity. During holidays a copy should be retained by the School.