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Northern Parade

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Medical and Consent Form

Medical and Consent Form

02392 662129/ 02392 662596
admin.np@kingsacademies.uk
Doyle Avenue Hilsea Portsmouth Hampshire PO2 9NE

Personal Details of Participant

First Name* Surname* Class (If Known) Date of Birth*

Male/Female*MaleFemale

Address* Postcode* Next of Kin - Name and address if different from above* Next of Kin contact number:* Work/Mobile Special Dietary Requirements

Medical Information

Name and address of participants Doctor:* Telephone Number:* NHS Number*

Has the participant had or have any of the following? (please tick)Asthma or BronchitisHeart ConditionFits, Fainting or BlackoutsSevere HeadachesDiabetesAllergies to any known medicationOther allergiesOther illness, disability or special needsTravel sickness or sleepwalkingRegular medication

If you ticked yes to any of these please give details below:

Is the participant receiving any of the followingSupport and/or treatment for mental health from their councillor or Doctor ?Medical or Surgical treatment of any kind from their Doctor or hospital?Has the participant been given specific medical advice to follow in emergencies?

If tyhe answer to any of these questions is yes please give details below (including name and dosage of any medicine/tablets).

If it is considered necessary, do you consent to mild painkillers (paracetamol) being administeres?*YesNo

If it is considered necessary do you consent to hypo-allergenic sun screen being provided?*YesNo

Has the participant received vaccination against Tetanus in the last 10 years?*YesNo

Consent for the visit

I confirm that i have parental responsibility for (Child's name)*

He/She is in good health and I consent to him/her taking part in ALL activities set out in the visit information.

I the event of illness or accident, I consent to any necessary medical treatment, which might include the use of anaesthetics.

In the event of any changes to these details, illness or medical treatment occurring after the return of this from and prior to the activity, I will undertake to inform the group leader.

Name* Date

Consent for programmes water sports and water related activities
(e.g. Kayak, Canoe, Sail, Windsurf, Rafting etc.; or activites involving water e.g. Caving, Gorge walking)

Please tick ONE of the boxes below as apropriate to confirm the water capability of your child.*A) I confirm my child can swim 50m and is water confidentB) I confirm my child can swim 25m and is water confidentC) I confirm my child is water confident and can swim, but I am not surer how far. They have been in a pool or other water and can submerge their head without becoming distressedD) I confirm my child is a non swimer, and may/or may not be confident in the water

Ticking A,B,C, or D above confirms your consent to your child undertaking water activities within the programme provided. This information will be passed on tho the provider by the school/college/establishment to allow appropriate adjustments or operating procedures for inclusive participation (as set out in HCC Registration information to providers).

If, for any reason, you wosh to withold consent fpr any activity, this should be detailed below. Name* Date*

King's Group Academies is a charitable and limited company registered in England and Wales, company number 09017776, registered at Lyndhurst Junior School, Crofton Road, Portsmouth PO2 0NT, tel: 02392 629949.

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