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.