Activity Information Form

Please complete this for each child who is attending the activity.

Event *

Name of Young Person *

First

Last

Section *

Emergency Contact Name *

First

Last

Emergency Contact Phone *

Doctor's Name and Surgery *

Details of any medication currently being taken

Details of any disabilities, conditions, allergies, dietary needs, special needs or cultural needs that might affect this activity:

Details of any infectious diseases they have been in contact with in the last three weeks:

Please give us any additional information which you think it important for us to know about the young person in the context of this activity

If it becomes necessary for the above named young person to receive medical treatment and I cannot be contacted to authorise this, I hereby give my general consent to any necessary medical treatment and authorise the Leader in charge to sign any document required by the hospital authorities. *

First

Last

Relationship to Young Person *

Date *

Custom Captcha *

Note: The medical profession takes the view that the parent’s/carer’s consent to medical treatment cannot be delegated. This view is explicit in The Children’s Act 1989. Thus, medical consent forms have no legal status and a doctor or nurse insisting on the consent of a parent/carer to a particular treatment has the right to do so.

For this reason we do not recommend that Leaders insist on parents/carers signing the statement above. However, it can be a comfort to medical staff to have general consent in advance from parents/carers or to have a Leader on hand able to sign forms required by medical authorities.

Should you have any concerns about any part of this form, please contact the leader in charge of the activity in question.

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Activity Information Form