PARENTAL CONSENT FORM FOR AN EDUCATIONAL VISIT
Please complete every section in full, then sign and return to Mr Hollingworth/ Mr Howe.
1. Details of Visit:
Destination: St Anton, Austria.
From date: 11/04/2014
To date: 19/04/2014

I have read and understood the information provided regarding the visit and agree to my child
_________________________________________ taking part in the above visit.

I understand the extent and limitations of the insurance cover provided.
Yes
No

I agree to my childs’ participation in the activities described:
Yes
No
Are there any activities that your child cannot take part in? If yes, provide details here:

I acknowledge the need for my child to behave responsibly and have spoken to them
regarding how they must conduct themselves whilst on the visit.
Yes
No
2. For activities in or near water (swimming ability and water confidence).

Is your child water confident?
Yes
No
Please describe your child’s swimming ability:
3. Medical Information.

Date of birth of your child (dd/mm/yy): ______________________

Does your child suffer from any conditions that the trip leader should be aware of, for example:
medical conditions, illness, allergies, night-time tendencies (sleepwalking, nightmares, bedwetting
travel sickness etc…)?
Yes
No
If yes, provide details here:

Does your child take any medication?
Yes
No
If yes, please give details of the medicine including how it should be administered, timings,
dosage and any possible side effects:

To the best of your knowledge has your child been in contact with any contagious/infectious diseases
or suffered from anything in the last four weeks that may be contagious or infectious?
Yes
No
Yes
No
If yes, please give details:

Is your child allergic to any medication?
If yes, please give details:

When did your child last have a tetanus injection? (To the nearest year) ________________

I agree to my child receiving medication as instructed and any emergency dental, medical or surgical
treatment, including anaesthetic or blood transfusion, as considered necessary by the medical
authorities present:
Yes
No

I agree to my child receiving pain killing medication such as Asprin, Paracetamol and Ibuprofen in the
event of feeling unwell, headaches and minor aches and pains etc….
Yes
No
These medications will only be administered as per manufacturers’ guidelines/dosages
and must be provided by the child, we will not provide any medication.

I will inform the visit leader/head teacher as soon as possible of any changes in
medical or other circumstances between now and the commencement of the visit:
Yes

No
Does your child have any special dietary requirements? For example vegetarian, vegan, food allergies
etc…
Yes
No
If yes, please give details:
4. Special educational needs and disabilities.
If your child has any special educational needs and/or disabilities which the school needs to
know about for this visit, please outline them here indicating how they may be supported for
this visit:
5. SKIING INFORMATION. VERY IMPORTANT - PLEASE ENSURE THAT THIS IS COMPLETED
AS IT ENABLES THE SKI HIRE COMPANY TO ENSURE THE CORRECT EQUIPMENT IS
AVAILABLE UPON OUR ARRIVAL.
Yes
Has your child skied before?
If yes, for how many weeks in total?
_________________

Childs weight (kg):
_________________

Childs height (cm)
_________________

Shoe size (European size 40, 41 etc):
_________________

No

Head Measurement (cm) _________________
(Please measure head as shown in diagram)
6. Contact information.

I can be contacted using the following telephone numbers/addresses: (Please complete in order of preference)
Contact number 1:
______________________
Contact name: ______________________
Contact number 2:
______________________
Contact name: ______________________
Contact number 3:
______________________
Contact name: ______________________
Home address: ______________________________________________________________________________
______________________________________________________________________________
Email: ______________________________________________________________________________________
Alternative Contact
Alternative Contact (name):
______________________
Relationship to pupil:
______________________
Number: ________________________
Address: ___________________________________________________________________________________
Name of family doctor: ______________________
Telephone Number:
__________________
Doctors address: _____________________________________________________________________________
7. I consent to my child taking part in this visit:
Signed: ________________________________________
Date _____________________
Full name (in capitals): ________________________________________________________________________

This form must be completed and returned to Mr Hollingworth / Mr Howe ASAP.