Italy and France with Acorn - 7TH August – 15th August 2015
Surname
First Name
Date of Birth
National Health Number
Doctors Name
Doctors Telephone Number
Doctors Address
HOSPITAL CONSULTANT (IF APPLICABLE)
Name of Consultant
Consultant Speciality
Hospital
Telephone Number
IN AN EMERGENCY THE FOLLOWING PERSON SHOULD BE CONTACTED
Surname
First Name
Relationship
Address
Daytime telephone
Evening
Mobile
Does the person to whom this form applies suffer from asthma, chest complaints, wheezing, hay fever, migraine,
fits or faints, bad period pains, diabetes, nervous disorders, any other illness or disability?
If yes please give full details
IF THE ABOVE CAN NOT BE CONTACTED IN EMERGENCY THE FOLLOWING PERSON SHOULD BE
CONTACTED
Surname
First Name
Relationship
Address
Daytime telephone
Evening
Mobile
Is the person to whom this form applies allergic to anything? (Antibiotics, any particular medicine, food, nuts,
wasp/bee stings? If yes please give details
Is the person to whom this form applies receiving any medical treatment at present? If yes please give details
Please give details of any current pills or treatments received
Has the person to whom this form applies had contact with any infectious illness within the last 12 months?
If yes please give details
Date of last Anti-Tetanus Injection
EMERGENCY PERMISSSION
I give permission for my child to receive any necessary medical or first aid treatment, for any illness or injury. I
also give my permission for any leader to give consent for any necessary hospital / medical treatment provided
reasonable attempts have been made to contact me.
Signed________________________________
Date ___________________________
Medication Available On Site
The following are available as appropriate, please indicate if any should NOT be given, and include a
brief explanation why.
Dosages will be in accordance with the recognised medical recommendation.
Paracetamol (tablets and elixir)
Ibuprofen (tablets and elixir)
Chlorphiramine e.g. Piriton (tablets and medicine) – for allergies
Antacid e.g. Gaviscon, Rennies (tablets and medicine)
Simple Linctus (cough mixture)
1% Hydrocortisone cream (not on faces)
Insect bite cream e.g. Waspeze, Anthisan
Calamine Lotion
Loperamide e.g. immodium
I give permission for the above to be given at the appropriate dose
Signed:- _________________________ Print:- ____________________ Date:-__________
Participants are expected to supply their own sun creams/blocks/moisturisers. We request that
participants who wear glasses bring a spare pair if possible; participants who wear contact lenses
must bring sufficient supplies.
Please advise of any pre-existing medical condition(s) as per table below, for:
Any person under 16 travelling within the UK / Europe
NO
✔
✔
✔
✔
Any person of any age travelling outside Europe
Any person 16 and over travelling to any destination
Any close relative*on whom the travel plans depend, even if not travelling
2. AFTER BOOKING but prior to departure :
Please advise of any changes in an ongoing medical condition or medication or a new
diagnosis as per table below, for:
All persons of any age or destination
Any close relative*on whom the travel plans depend, even if not travelling
*For the adults travelling on the trip, this also includes any close business associate.
ADDITIONAL INFORMATION (including any information you think may be relevant)
A copy of the Key Facts and Insurance Policy can be found a read at
www.acornadventure.co.uk.
YES
NO
YES
✔
✔