Activity & Health Permission Form - Dorridge Scout Group, Cole, Solihull County printable pdf download

Dorridge Scout Group, Cole, Solihull County

MSB V1 Feb 2012

Activity & Health Permission Form

Scout’s Full Name: ______________________________________

Date of Birth: ___________________

Scout’s Home Address: ____________________________________________________________________

If the answer to any of the following questions is YES, please give details overleaf.

1) Has your child been in contact with any infectious diseases within the last 3 weeks?

Yes / No

2) Is your child receiving any medical treatment at present?

Yes / No

3) Is there any medical condition which would need to be made known to a Doctor?

Yes / No

4) Is any medication currently required?

Yes / No

(If YES, hand to expedition leader with scout’s name affixed & full directions)

5) Are there any allergies to food, medicine, environment (e.g.: Hay fever etc)?

Yes / No

6) Are there any particular dietary needs?

Yes / No

7) Does your child have any special needs?

Yes / No

8) May your child, under supervision, undertake adventurous activities

Yes / No

Permission To Administer the Following Medicines:

a) Paracetamol Suspension

Yes / No

(e.g.: calpol)

b) Chlorpheniramine

Yes / No

(e.g.: piriton)

c) Ibuprofen

Yes / No

(e.g.: nurofen)

[Note: cannot be given to under 12s]

d) Levomenthol & Ibuprofen

Yes / No

(e.g.: deep relief – re. muscular aches)

[Note: cannot be given to under 12s]

e) Menthol & Camphor

Yes / No

(e.g.: radian b – re. muscular aches)

f) Phenol & Chlorhexidine Digluconate

Yes / No

(e.g.: germolene)

g) Elastoplast

Yes / No

(e.g.: plasters)

Doctor’s Name: Dr _______________________

At: ___________________________________________

Doctor’s Address ___________________________________________________ Tel: _____________________

Parent/Guardian Emergency Contact Details:

Name: _____________________________

Home Tel: __________________ Mobile: __________________

Name: _____________________________

Mobile: __________________

I consent to my child undertaking activities with the Scout Association and its agents.

Adventurous Activities: Hiking, Climbing, Canoeing, Caving, Swimming, Scrambling, Mountain Biking, Shooting etc

The Natural Environment: Participation in adventurous activities entails some or even considerable risk of injury.

Nature is unpredictable and unsafe. Mountains are dangerous. Scout leaders and trained persons run activity sessions

and will at all times proceed in a manor to limit the risk of injury. However, you need to accept that accidents and

injuries can happen.

Behaviour: I understand that the Scout Leader in charge reserves the right to send any participants home if necessary.

If it becomes necessary for my child to receive medical/dental treatment and I cannot be contacted by telephone or

any other means to authorise this, I hereby give my general consent to any necessary medical/dental treatment and

authorise the Scout Leader in charge to sign any document required by the medical/dental authorities.

Activity & Health Consent Signature: ____________________________

Dated:

____________________

of parent / guardian

Note: The medical/dental professions take the view that the parent’s consent to treatment cannot be delegated. This view is explicit in the Children Act 1989. Thus

consent forms have no legal status and a doctor/nurse etc insisting on the consent of a parent to a particular treatment has the right to do so. For this reason we do

not recommend that Leaders insist on parents signing the statement above. However, it can be a comfort to medical/dental staff to have general consent in advance

from parents or to have a Leader on hand able to sign forms required by these professions.