Downloads Torksey Consent

Torksey

September 03

SPECIAL EVENT/ACTIVITY CONSENT FORM

PART A (To be completed by The Boys’ Brigade)

Company/Battalion/District __Ist_Dronfield___________________________________________________

ActivityorEventTorksey_Camp_____________________________________________________Venue ____Torksey_Polish_Scout_Camp Torksey_______________________________________________

Dates _10-12th_June_2011___________________________________________________

Officer in Charge _Tony_Drury-Smith____________________________________________________

PART B (To be completed by the Parent/Guardian)

Full name of member______________________________________________________________

Date of birth _________________________

PERMISSION

I give my permission for ___________________________ to attend and take part in the activities or

event named in Part A. I understand that in the event of any illness or accident, every effort will be

made to contact me, but if this is not possible, I authorise any Officer to sign on my behalf, any written

form of consent required by medical authorities.

MEDICAL DETAILS

Name and address of young person’s Doctor___________________________________________

_______________________________________________________________________________

_____________________________ Doctor’s Telephone Number __________________________

National Health Service Number _____________________________________________________

Details of any infectious disease with which there has been contact within the last three weeks

___________________________________________________________________________________________

Details of medicine/diet/treatment which is being taken/followed____________________________

_______________________________________________________________________________

Details of known allergies/sensitivities (e.g. penicillin) ____________________________________

_______________________________________________________________________________

My child has/has not* been immunised against tetanus within the last five years.