Sefton Music Service
PARENT/CARER CONSENT, MEDICAL AND EMERGENCY CONTACT FORM
Sefton Young Musicians
TOUR TO MONS, BELGIUM
23rd - 27th OCTOBER 2015
Child’s Name ....................................................…................................... DoB………….…………
Member of Ensemble/s…………………...............................................................................................
Address
…………………………..........................................................…………………...……...
Home & Emergency Telephone Nos …...................................................………………………………
Dietary requirements .…....………………………………………………………………………………….
Doctor's name and address ...................................................................................………….………...
N.H.S. No.........................…………..…....………..Blood Group ..……………..........................If known
Is your child currently undergoing medical treatment or taking medicines? If so please give details:
………..……………………………………………………………………………………………………….
Please give details of any medical conditions, allergies etc that might possibly affect your child:
………..……………………………………………………………………………………………………….
Statement
I acknowledge receipt of the information regarding the tour to Mons in October 2015 and consent to
my child, named above, participating.
I agree to Sefton Music Service tutors giving permission for my child to receive medical treatment in
an emergency.
I undertake to inform Sefton Music Service in the event of any changes in my child's fitness prior to
the start of the visit.
I have ensured that my child understands that it is important for his/her safety and for the safety of the
group that any rules and any instructions given by the tutors in charge are obeyed.
If my son/daughter does not conform to the instructions and rules given, then I will meet the full cost
of transporting them (before the end of the tour) from Belgium back to their home.
Signed..............................……………........................ Parent/Carer Date…………………………
Please indicate relationship to child …………………………………………………………………..
Please return to Sefton Music Centre, Redgate, Formby, Liverpool, L37 4EW ASAP or before
Friday 1 May 2015 at the latest. KEEP ONE COPY FOR REFERENCE.
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