Health Information Form

Health Information Form

This section to be completed by the Leader

Activity and Location

From To

Activity Leader

Assistant Leaders

This section (both sides) is to be completed by the Parent or Guardian of the young person named below. Please answer the following

questions as fully as possible. As in the event of your child requiring emergency treatment, it will help the medical authorities in deciding

which is the most appropriate treatment to give.
(Please complete in BLOCK CAPITALS)

Surname

Date of Birth

Forenames

National Health Service Number

He/She may bathe under careful Supervision.. Yes ¨ No ¨

Date of last Tetanus injection

Parent/Guardians Address During the Camp/Holiday

....................................................................................................

Telephone

Family Doctors Name and Address

....................................................................................................

Telephone

I hereby give permission for my child to attend the aforementioned Activity.

If it becomes necessary for my child to receive medical treatment and I cannot be contacted by telephone or any other means to authorise this,

I hereby give my general consent to any necessary medical treatment and authorise the Activity Leader named overleaf (or in their absence

one of the Assistant Leaders named overleaf), to sign any document required by the hospital authorities.

I will inform the Activity Leader if any of the information given on this form changes before the event takes place.

Name of Parent/Guardian

Relationship to Young Person

Signature

Date

The Activity Leader (or in their absence one of the Assistant Leaders named overleaf) may administer the appropriate minor treatment/precautions (as listed below ) if required.

Headache.............................................................................................................................................................................................................

Stomach Upset....................................................................................................................................................................................................

Cuts & Grazes.....................................................................................................................................................................................................

Colds etc..............................................................................................................................................................................................................

Other Specific Ailments......................................................................................................................... Please continue below if required.

In the space below please give details of the following:-

1..... Any Known Infectious Diseases with which Your Child (named overleaf) has been in contact within the last three weeks (e.g. Chicken Pox, Diphtheria, Measles, Mumps, Rubella, Whooping Cough etc.)

2..... Any Known Allergies/Sensitivities/Disabilities and details of any known precautions or remedies
(e.g. Penicillin, Food Colourings, Travel Sickness, Bed-wetting, Asthma etc.)

3..... Details of any Medicines/Diets/Treatments currently being Taken/Followed (including dosage details) & the Specialist and Hospital concerned if appropriate (please include any non prescription preparations, such as cough sweets , herbal medicines).

(If He/She has to take any Medicine's, the bottle(s), jar(s) or other items should be clearly labelled with their) (name and the exact dosages, and should be handed to the Activity Leader/First Aider before departure. )

...............................................................................................................................................................................................................................

Please continue on a separate sheet if required (Remember to include your child(s) name on any separate sheets and attach them securely to this form)