Parental Consent For Educational Tour/field Trip Form
ADVERTISEMENT
1Cavan and Monaghan Education and Training Board
Declaration
Form ST5 PARENTAL CONSENT FOR
I/we agree to my/our son/daughter receiving medication as
EDUCATIONAL TOUR/FIELD TRIP
instructed and any emergency dental, medical or surgical
Carrickmacross Youthreach
treatment, including anaesthetic or blood transfusion, as
considered necessary by the medical authorities present. I
Details of visit to:
understand the extent and limitations of the insurance cover
Monaghan Leisure Centre
provided. I further agree that supervisors, under the
direction of the group leader, may administer non-
th
From: Friday 29
Jan 2016 9:30am
prescriptive medications in accordance with the
th
To:Friday 29
January 12:30pm
manufacturer’s instructions.
I agree to ______________________________________
Ability To Swim
Date of birth __________________ taking part in this
Give details of your child’s ability to swim
tour/trip and have read the information document.
________________________________________
I agree to participation in the activities described.
Other Relevant Information:
I acknowledge the need for the student named above to
_______________________________________________
behave responsibly and in accordance with the Behaviour
Contact telephone numbers
Policy of the school and of Co. Monaghan VEC. I accept
that any student who uses, supplies or is found to be in
Work:_____________________________
possession of drugs, alcohol, solvents, inhalants or other
Home:___________________________________
dangerous substances and/or who engages in behaviour or
actions that are deemed to be a risk to the safety of any
Home
member of the group will result in the offender being sent
address:_________________________________________
home immediately and we the parents will bear the resultant
________________________________________________
costs.
Alternative emergency contact:
Medical information about your child
Name:________________________________
a) Any conditions requiring medical treatment, including
Telephone number:______________________
travel sickness, and medication required? Y/N
Address:_________________________________________
If YES, please give brief details:
___________________________ ____________________
________________________________________________
Name of family
b) Please outline any special dietary requirements (resulting
doctor:__________________________________________
from a medical condition) of your child and the type of pain
Telephone
or cold/flu relief medication your child may be given if
number:__________________________________
necessary:
________________________________________________
Address:_________________________________________
_____________________________________________
Students may not bring non-prescribed medication with
them. The school will supply this type of medication as per
the information supplied. (Checked with GP)
Signed: ________________________________ (Parent 1)
c) Does your child suffer from any condition requiring
prescribed medication? Y/N
________________________________ (Parent 2)
If Yes please give FULL details of illness and/or
medication:
________________________________________________
Date: _________________________________
d) To the best of your knowledge, has your son/daughter
I have read and understand the meaning and implications
been in contact with any contagious or infectious diseases
regarding all aspects of this form
or suffered from anything in the last four weeks that may be
contagious or infectious? YES/NO
Signed: ________________________________ (Student)
If YES, please give brief
details:__________________________________________
Date: _______________________________
e) Is your son/daughter allergic to any medication including
Full name (capitals)
non-prescriptive medications? Y/N
_______________________________________________
If YES, please
A COPY OF THIS FORM MUST BE TAKEN BY THE GROUP
specify:_________________________________________
LEADER ON THE TOUR/TRIP.
I will inform the Group Leader/Principal as soon as possible
THE ORGINAL SHOULD BE RETAINED BY THE SCHOOL
of any changes in the medical or other circumstances of my
CONTACT.
son/daughter between now and the commencement of the
journey
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal