BEBINGTON DISTRICT EXPLORER SCOUTS

EXPLORER PERSONAL DETAILS

FULL NAME: ADDRESS: D.O.B.: TEL: MOB: EMAIL:

POSTCODE: SCHOOL:

NEXT OF IN DETAILS (1)

FULL NAME: ADDRESS (IF DIFFERENT): RELATION:

WOR TEL: EMAIL:

MOB:

NEXT OF IN DETAILS (2)

FULL NAME: ADDRESS (IF DIFFERENT): RELATION:

WOR TEL: EMAIL:

MOB:

EXPLORER MEDICAL DETAILS

(PLEASE CONTINUE OVERLEAF IF NECESSARY)

GP: TEL: ADDRESS: POSTCODE: NHS NUMBER: MEDICAL CONDITIONS/MEDICATION:

SPECIAL NEEDS (DIET/EDUCATIONAL) OR ALLERGIES:

PLEASE READ THE FOLLOWING STATEMENTS BEFORE SIGNING: I ACCEPT THAT THE UNIT WILL BE EEPING INFORMATION ABOUT MY CHILDS MEMBERSHIP AND I UNDERSTAND IT WILL BE USED FOR SCOUTING PURPOSES ONLY. IF IT BECOMES NECESSARY FOR MY CHILD TO RECEIVE MEDICAL TREATMENT AND I CANNOT BE CONTACTED BY ANY MEANS TO AUTHORISE THIS* I HEREBY GIVE MY GENERAL CONSENT AND AUTHORISE THE LEADER IN CHARGE TO SIGN ANY DOCUMENT REQUIRED BY THE HOSPITAL.

SIGNED (PARENT/GUARDIAN/CARER):

DATE: