Medical Consent Form

MEDICAL CONSENT FORM

This form should be completed by a parent/guardian before your child can participate in a club activity.

One form should be completed for each child/young person.

Name

Date of Birth

Address

Postcode:

Tel No.

Contact Address

(if different to above)

School

Name of Doctor

Doctor’s Address

Doctor’s Tel No

Child’s Medical No

Any specific medical conditions requiring medical

Yes

treatment and/or medication?

If Yes, please give details

Any allergies

Yes

If Yes, please give details

Any contact with contagious or infectious diseases

Yes

within the last four weeks?

If Yes, please give details

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Parent category: Legal