Educational Visit Consent & Medical Form

This form is to be completed and signed by students over 18 years of age or by a parent or guardian for students

under 18 years of age and SLDD students under 25 years of age. PLEASE COMPLETE IN BLOCK CAPITALS

Visit to:
DETLING UCAS EVENT - FRIDAY 15 t h MARCH 2019
Student’s name:

Are there any activities in which you/your son/daughter/ward should not participate. If so, please give details:

Name, address and contact details of student’s doctor:

Are you/is he/she allergic to anything, e.g. medicines, food, pollen, etc? If so, please give details:

Do you/does he/she suffer from any of the following? Asthma, chest complaints, migraine, bad period pains,
travel sickness, diabetes, fits or faints? If so, please give details:

Are you/is he/she having any medical treatment at present? If so, please give details of treatments and
medicines: (Please remember that prescribed medicines may be handed in, before departure, to the staff in charge in their original,
labelled box / bottle for safe keeping.)

Do you/does your son/daughter/ward have any physical disability? Please give details of any special attention
required:

Please use this space to inform the staff in charge, in confidence, of any other medical condition or health
problem that may affect you/your son/daughter/ward during this visit: (If you would prefer to communicate confidential
information in writing to the party leader, please do so.)

Date of last anti-tetanus injection:

Please indicate any special food / dietary requirements:

! In the event of me/my son/daughter/ward not conforming to the standards of behaviour required by the
member of staff in charge of the visit, I will personally be responsible for all arrangements to get
myself/my son/daughter/ward home.

I, _________________________________________ give consent to my medical examination/the medical examination of my

son/daughter/ward when necessary whilst I am/he/she is taking part in the visit and I request that any operation or any other
measures considered necessary, by a medical authority, for my/his/her diagnosis and treatment shall be performed and I hereby give
permission for such an operation or other measures to be carried out in an emergency only and for the administration of general or
local anaesthetic if necessary.
I am willing / not willing to take part/for my son/daughter/ward to take part in the visit detailed and, having read all the
information provided, agree to taking part/him/her taking part in any of the activities mentioned except those specified.

Signed: _______________________________ Date: _______________________________