Health and Consent Form

(please complete all sections of the form)

I give permission for: Name_________________________________________________

Address____________________________________________________________ ___________________________________________________________________
Date of Birth _______________ To attend the activity called: Date of activity: 16/17/05/2014 Does your child have a medical condition or disability? I so !lease "ive details: Blac pool !lay"one Age ________ yes #es No No

Does your child need medication or su!!ort or any o the ollo#in"? Diabetes &aintin" or 'lac(outs )!ile!sy *sthma/+ay ever ,ravel -ic(ness *ller"ies: Details: $es $es $es $es $es $es %o %o %o %o %o %o I yes !lease "ive details:

*s ar as I am a#are my child has not been in contact #ith any infectio$s diseases or the last three #ee(s and is in "ood health. In the event o my child bein" ta(en ill or in/ured durin" the !ro/ect named above0 I authorise the leader !resent to administer first aid%accompany my child to hospital or si"n on my behal any orms o consent #hich may be re1uired by the medical authorities0 !rovided that the delay to obtain my si"nature mi"ht be considered li(ely0 in the o!inion o the doctor or sur"eon0 to endan"er the health or sa ety o my child.

I understand that durin" the !eriod o the event named above0 my child #ill be in the char"e o the leaders !resent and under their instructions0 and & accept that my child may 'e ret$rned home i in the o!inion o the leader in char"e0 he or she has behaved in a #ay #hich is unacce!table under normal circumstances.

Is your child ta(in" any sort o medicine or medical treatment?: I $)- !lease "ive details belo#:

#()

N*

%ame o 2edicine: ___________________________________________________ ,reatment: Dosa"e: ___________________________________________________ ____________________+o# o ten? _________________________

&f any prescri'ed medicines named a'ove need to 'e ta en +hilst yo$r child is on the named event, it is yo$r child-s o+n responsi'ility to administer the medicine. %ame o Doctor: ________________________

%ame 3 *ddress o -ur"ery ___________________________________________________ ,ele!hone %umber: _______________________

1. 4e"islation re1uires that youn" !eo!le under the a"e o ei"hteen should have consent to !artici!ate in the above named activity countersi"ned by a !arent or le"al "uardian #ho has res!onsibility or that youn" !erson.
I AM WILLING TO ALLOW MY CHILD TO PARTICIPATE IN THE FULL PROGRAMME OF ACTIVITIES AS OUTLINED IN THE INFORMATION SHEET OR LETTER

)igned (!erson +ith parental responsi'ility):_______________________________

Name in Capitals: ____________________ Date:________________________________ Tel No. in case of emergency:_______________________________________________ Address (if different to the yo$ng persons address overleaf)

&t is essential that another contact n$m'er 'e given (either yo$rs or someone else-s) in case of emergency or cancellation of an activity +here'y yo$r child is ret$rned home. Name____________________________________________________________________ /elationship to participant: _______________________________________________ Tel. No.__________________________________________________________________

I GIVE CONSENT FOR MY CHILD TO GO on the above activitie )igned (!erson +ith parental responsi'ility):_______________________________

!(/0&))&*N T* 1)( !H*T*2/A!H) AND )HA/( !A/T&C!ANT)- !(/)*NA3 &NF*/0AT&*N The data protection act requires that before the publication of images of people and the recording of information supplied, consent must be sought and given. 4. 5e there ore re1uire consent or their !hoto to be used in a !resentation board/re!ort/#ebsite/ne#sletter/!ublicity material 6delete any not acce!table7 to !romote the youth club and 4eonard 8heshire Disability. ,he ima"e6s7 #ill not be used or co!ied or any other !ur!ose. I understand that my child #ill not be named and urther consent #ill be obtained i #e need to 6such as in a re!ort7 or i the !hotos #ill be used or any other !ur!ose. I GIVE CONSENT FOR PHOTOGRAPHS TO !E USED FOR PU!LICITY" )igned (!erson +ith parental responsi'ility):_______________________________

5. 5e also re1uire consent or their contact details and !ersonal in ormation to be securely stored #ith 4eonard 8heshire Disability or use in statistical monitorin" and may be shared0 i necessary0 #ith our !artner a"encies includin"9 Ins!ira0 8umbria 8ounty 8ouncil0 !rivate unders0 activity !roviders. I #e need to share the in ormation #ith any a"ency other than those listed #e #ill irst obtain your consent. I GIVE CONSENT FOR STATISTICAL INFORMATION TO !E SHARED" )igned (!erson +ith parental responsi'ility):_______________________________