Parental Medical Consent Form
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3SCHOOL TRIP
PARENTAL MEDICAL CONSENT FORM
Data Protection Act. The information being collected on this form will only be used for the purpose
of the school administration of visits and journeys under Department of Education and Skills
guidelines. The data will not be disclosed to any external sources other than in an emergency, or to
the Local Education Authority, without your written consent.
1.
Description of Activity: DUKE OF EDINBURGH EXPEDITION
2.
Date of activity:
Practice: ………………………………….
Assessment:……………………….……………..
3.
Name of participant:………………………………………………………………………..…………………………………..………….…………
4.
Address:……………………………………………………….………………………………………………………………………………………………
…………………………………………………..……………………………………………….…………………………………………………………….…………………
……………………………………………………………………………………………………………………………….………………………………..…………………
5.
Tel No:…………………………………………………………….……………………………………………………….………
6.
Age:…………………..……………………….……
Date of Birth: ……….…………………………………………………………
7.
Alternative Address & Tel No: ……………………………………………………………………………………………………..……………
………………………………………………………………………………………………………………………………………………………………….…………
……………………………………………………………………………………………………………………………………………………………………….……
Please give details requested below or personal information which
8. Personal Information:
might be relevant.
(a)
Has your child, to your knowledge, been in contact with any infectious illness in the last
three weeks?
YES / NO
please circle
(
) If yes, give details: ………………………………………………………………..
……………………………………………………………………………………………………….…………………………………..………………
(b)
Does your child suffer from allergies, Diabetes, Migraine, Epilepsy, bad period pains or
any other illness or disability?
YES / NO
please circle
(
)
If yes, give details……………..………………………………………………………..…
……………………………………………………………………………………………………….…………………………………..………………………
…
(c)
Is he/she allergic to anything (e.g. antibiotics, Elastoplasts, Aspirin or any such medicines,
any particular food etc)?
YES / NO
please circle
(
) If yes, give details………………………………………………………….………………
……………………………………………………………………………………………………….…………………………………..………………………
…………………………………………………………………………………………………………………………………………………………………..
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