Health and Information Form	
This section to be completed by the Event Leaders
Event Location: 		From: 
To: 	

Event Leader:

	Home Contact:

 		Assistant Event Leaders: 

The sections on both pages need to be completed by a parent/guardian/partner/spouse of the individual named below that is NOT attending the event.  WE REQUIRE ALL SECTIONS COMPLETED. NO EXCEPTIONS. In the event of your child requiring emergency treatment, it will help the medical authorities in deciding which the most appropriate treatment to give is.
IF WE DO NOT THE CORRECT OR FULL DETAILS WE CAN REFUSE TO TAKE PARTICIPANTS ON EVENTS.
(Please complete CLEARLY in PRINTED BLOCK CAPITALS with BLUE or BLACK INK)

FULL NAME: 		DATE OF BIRTH:
D	
D	
M	
M	
Y	
Y	

PLEASE CIRCLE THE CORRECT STATEMENT
PARTICIPANT MAY BATHE UNDER CAREFUL SUPERVISION:   YES / NO

PARTICIPANT CAN SWIM 50 METRES:   YES / NO

PARTICIPANT CAN TREAD WATER FOR 5 MINUTES:   YES / NO
		DATE OF LAST TETANUS INJECTION:
M	
M	
Y	
Y	
Y	
Y	

PARENT/GUARDIAN CONTACT ADDRESS DURING EVENT:

POSTCODE: 
HOME TELEPHONE: 
FATHER NAME: 
MOBILE: 
MOTHER NAME: 
MOBILE: 		FAMILY DOCTOR NAME & ADDRESS:

DOCTOR’S NAME: 
ADDRESS: 

POSTCODE: 
TELEPHONE: 	
		NATIONAL HEALTH NUMBER:	

I hereby give permission for the person named above to attend the aforementioned event.

If it becomes necessary for the attendee of the event 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 event leader named above (or in their absence one of the assistant event leaders named above), to sign any document required by the hospital authorities.

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

PARENT/GUARDIAN NAME: (PRINTED) 		REPLATIONSHIP TO PARTICIPANT: 	

SIGNATURE:		DATE: 	

The event Leader (or in their absence one of the assistant event leaders named overleaf) may administer the appropriate minor treatment/precautions (as listed below ) if required. PLEASE CIRCLE CORRECT ANSWER:

Headache:   YES / NO

Stomach Upset:   YES / NO

Cuts & Grazes:   YES / NO

Colds etc:   YES / NO

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 Camp Leader/First Aider before departure. )

IF NONE OF THESE APPLY TO THE PARTICIPANT, PLEASE “NOT APPLICABLE” CLEARLY IN THE SPACE BELOW

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)