Nights Away Permission Medical Consent Form printable pdf download

NIGHTS AWAY PERMISSION & MEDICAL CONSENT FORM

I give permission for ……………………………………………………… to take part in Christmas Camp to Gradbach

Scout Campsite from Friday 16

– Sunday 18

December 2011. The details I provide are correct at this time

and I will inform Sian Stockham if they should change prior to departure.

In the event of an emergency during the weekend please contact Sian (07979814980), Nick (07919868487)

or Tony (07870644491) before making direct contact with the Explorer Scout.

Please complete and return this form to Sian on or before Monday, 7

December 2011.

The following medication will be available during this

Date of birth: _ _ / _ _ / _ _ _ _

event. Do you authorise Sian Stockham, Tony

Please give any further details relating to

Richardson or Nick Bryan to administer this as

necessary?

health questions on reverse of this form

Paracetamol

(2 x 500mg)

Yes/no

•

Has he/she been in contact with any infectious

Ibuprofen

(2 x 200mg)

Yes/no

•

Travel sickness tablets

Yes/no

diseases within the previous three weeks? yes/no

•

SPF 15 sun cream

Yes/no

•

Date of last tetanus immunisation:

SPF 30 sun cream

Yes/no

•

Plasters

Yes/no

………………………………………………………………

•

50% DEET insect repellent

Yes/no

•

Any medicines currently being taken:

Anthisan cream

Yes/no

•

Savlon cream/spray

Yes/no

………………………………………………………………

•

Antihistamine tablets

Yes/no

•

Does he/she have any allergies to food, medicines

Antiseptic wipes

Yes/no

•

or other: yes/no

Explorer Scouts should make Sian, Tony and Nick

Does he/she suffer from asthma, chest complaint,

aware of any medication they require and ensure it

is clearly marked with name and full instructions

wheezing or hay fever, migraine, fits or faints, bad

for use. Exceptions: inhalers and epi-pens, which

period pains, diabetes, nervous disorders, any

should be retained by the Explorer Scout. (Spare

inhalers should be given to the First Aider.)

other illness or disability? yes/no

I understand that the event Leader reserves the right to

Does he/she have any special needs: yes/no

send any participants home if necessary. If it becomes

Name and address of own doctor:

necessary for my child to receive medical 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 treatment and authorise Sian Stockham

………………………………………………………………………

or Nick Bryan to sign any document required by the

…………………………………………………………………

hospital authorities.

My emergency contact details are:

Signature of parent/guardian:

Name: ……………………………………………………….

……………………………………………………………………………………

Relationship: ………………………………………………..

Date: …………………………………………………………………………

Address:……………………………..……………………………

……………………………………………………………..

Note:

the medical profession takes the view that the

parent’s

consent

medical

treatment

cannot

………………………………………………………………

delegated. This view is explicit in the Children Act 1989.

Thus medical consent forms have no legal status and a

…………….…………………………………………………

doctor/nurse insisting on the consent of a parent to a

particular treatment has the right to do so.

For this

Telephone numbers:

reason we do not recommend that Leaders insist on

parents signing the statement above. However, it can be

1) …………………………………………………………

a comfort to medical staff to have general consent in

advance from parents or to have a Leader on hand to sign

2) …………………………………………………………

forms required by medical authorities.

All activities will be run in accordance with The Scout Association’s safety rules. No responsibility for the personal

equipment/clothing and effects can be accepted by the event organisers and The Scout Association does not provide

automatic insurance cover in respect to such items.

Nights Away Permission Medical Consent Form

Related Articles

Related forms

Related Categories