QE2 Activity Centre

Manor Farm Country Park, Pylands Lane, Bursledon, Hampshire, SO1 1BH

 

2016 CONSENT FORM

 

NAME OF PARTICIPANT ...........................................

DATE OF VISIT …………………

NAME OF GROUP ...........................................

AGE IF UNDER 18 …………

ADDRESS ............................................

.........................................

............................................

TELEPHONE ......................................

 

MEDICAL INFORMATION

EMERGENCY CONTACT

NAME .................................................. RELATIONSHIP ...........................

ADDRESS .................................................. …………………………………….

 

TELEPHONE ................................................(day) ........................................(evening)

MOBILE ................................................

 

Please give details of disability, illness or injury below


adhd

asthma

autism spectrum condition

axial instability

bronchitis

challenging behaviour

diabetes

epilepsy

fits or fainting

heart condition

learning disability

muscle weakness

physical disability

sensory impairment

other (please specify)


If the answer to any of these questions is yes, please give details

 

 

If it is considered necessary do you agree to mild painkillers (eg Paracetamol) being administered yes/no

 

If it is considered necessary do you consent to hyper-allergenic sun screen being provided to prevent sunburn yes/no

 

Have you received vaccination against Tetanus in the last ten years? yes/no

 

Are you currently receiving medical treatment? yes/no

 

Have you been given specific medical advice to follow in an emergency? yes/no

 

Do you have any allergies to food or medicine which we should be aware of? yes/no

 

If the answer to any of these questions is yes, please give details

 

CONSENT

I have given full medical details. I consider that I am capable of participating in the activities organised by the Centre. I consent to taking part in the activities provided by the Centre. In the event of illness or accident I give my consent to any necessary medical treatment.

 

 

Signed ............................................... (participant over 18)

 

 

 

Signed ............................................... (parent/guardian if participant under 18)

 

 

 

WATER SPORTS

Where water sports are part of the intended programme, please tick one of the boxes below to confirm your water capabilty:

I am water competent (I confirm I can swim 50 metres in a pool or sea)

I am water confident (I confirm I can swim 25 metres in a pool or sea)

I am water comfortable (I confirm I have been in a pool or the sea and can submerge my head under water without becoming distressed)

I am not water comfortable

I consent to participating in water sports at the Centre yes/no

 

 

Signed ............................................... (participant over 18)

 

 

Signed ............................................... (parent/guardian if participant under 18)

 

 

PHOTOGRAPHS

We sometimes take photographs for educational or display purposes

 

    I don’t mind having my picture taken

    I don’t want to have my picture taken

 

 

Signed ............................................... (participant over 18)

 

 

Signed ...............................................