Download Emergency Contact, Medical and Activity Capabilities Name of Pupil

Emergency Contact, Medical and Activity Capabilities
Name of Pupil
Parents Phone Contact Details During Visit
Day Phone
Eve/Night Phone
Does your child require any special dietary considerations
Yes
No
Does your child suffer from any condition or injury that may impact on the
activities to be undertaken
If Yes please provide details –
Yes
No
Does your child use medication on a regular basis
Yes
No
Yes
Yes
Yes
Yes
No
No
No
No
If Yes please provide details –
If yes please provide details, including dosage.
Is your child allergic to any of the following Any medication
Any food types
Contact with animals / plants
Other allergies
If Yes to any of the above please include details –
Swimming Ability – please indicate
Activities at height – please indicate
Being in enclosed spaces
Confident
Happy
Happy
Weak
Uncomfortable
Uncomfortable
Non-Swimmer
Unknown
Unknown
In a situation where your child would require medical attention beyond basic First Aid the accompanying
staff would make every effort to contact you. However in an emergency this may not be practicable and
it may be that medical treatment may become necessary without you being able to provide verbal
consent. For this reason we ask that you read and sign the declaration below.
Declaration
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 qualified medical
authorities present.
Parents Name ……………………………………… Signed……………………… Date ………..…..