Medical and Consent Information Form

Participant's full name *

First

Last

Home address *

Date Of birth *

Contact name *

First

Last

Relationship to participant *

Secondary contact name *

First

Last

Relationship to participant *

Primary contact number 1 *

Primary contact number 2

Primary contact Email *

Secondary contact number 1 *

Secondary contact number 2

Secondary contact Email *

Doctor's address and contact number

Has the participant had any of the following? (Please tick)

Asthma/Bronchitis
Sight/hearing difficulties
Heart condition/ High blood pressure
Epilepsy
Allergies: e.g. nuts, pollen, drugs/medicine, latex, plasters, plants, food, other materials
Severe headaches
Fits, fainting or blackout
Have they ever been stung by a wasp or bee?

If yes to the above, please give details and Medication needed.

Date of last tetanus injection

Are immunisations up to date?

Yes
No

Do you give permission for;

Staff to apply sun cream and insect repellent to exposed areas of your child’s skin?
Staff to use wet wipes on your child’s skin?
Staff to administer antihistamine?
Staff to administer an epi-pen, inhaler, insulin or any other drugs if applicable and required?
Staff to administer first aid if necessary?
Participation in all forest school activities including fire making and tool use.

Does the participant have any of the following: (Please tick)

Any other illnesses
Any disabilities
Special dietary requirements

If the answer to any of the above is YES, please give details below, including details of medication or special diet:

Does the participant have any other issues we should know about. For example ADHD, ASD, SEN, any other learning/ behavioural/ emotional difficulties or issues?

I GIVE MY PERMISSION FOR THE PARTICIPANT TO BE TRANSPORTED TO HOSPITAL AND TO RECEIVE EMERGENCY TREATMENT IF NECESSARY.

Yes
No

Signed: (E-signature) *

Relationship to participant: *