Generic Consent Form

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Generic Consent Form

Parental Consent Form

My Son ………………………………… ………………….will attend the Survival camp from Friday 7th to Sunday 9th June 2013 and the following is provided for the benefit of the Camp Leaders Jamie Vickery and Phil Connor.

Date of last Tetanus immunisation………………………………………………………………………………………

Medicines currently being taken …………………………………………………………………………………………

Is he allergic to anything (eg aspirin, antibiotics, any particular food or drugs) ? If so please give details. ……………………………………………………………………………………………………………………………

Does he have any special dietary needs? …………………………………………………………………………….

Has he any mobility difficulties or other disability ………………………………………………………………

He MAY/MAY NOT participate in water activities under careful supervision.

His National Health Number is………………………………….. and Date of Birth …………………..

Name and Address of the Family Doctor……………………………………………………………………
…………………………………………………………………………………………………………………………….

During the event from dates………………to …………….my address will be………………………………………………………………………………………………………………..Tel No …………………………

and from dates………………..to ……………….. it will be ……………………………………………………………………………………………………………………………………………..
Tel No………………………….

I will inform you if my son has been in contact with any infectious disease three weeks prior to the event.

If it becomes necessary for my son to receive medical treatment and I am not contactable by telephone or by any other means , I hereby give my general consent to any necessary medical treatment and authorise Jamie Vickery or Phil Connor or a representative of the Scout Association to sign any document required by the hospital authorities.

Signed (Parent or Guardian) …………………………………………………………………………………………………….

Mobile number…………………………………………………………………………………………………………

Home telephone number………………………………………………………………………………………………