Coven 2004

Dear Parents,

STAFFORDSHIRE COUNTY COUNCIL EDUCATION SERVICE FORM EVM (2003)

MEDICAL FORM FOR PUPILS ATTENDING A RESIDENTIAL VISIT OR OUTDOOR EDUCATION CENTRE.

To be completed by a person with parental responsibility not more than seven days prior to the starting date of the visit

IF THE ANSWER TO ANY OF THESE QUESTIONS IS YES PLEASE GIVE FULL DETAILS OVERLEAF
(Please tick the appropriate answer)

1. Is your child receiving any medical treatment at present?
YES NO

2.. Has-your-child been in contact with-anyone suffering from an infectious disease in the last four weeks or suffered any infection within the last four weeks that may be infectious or contagious? YES NO

3. Has there been any diarrhoea and or vomiting during the last seven days? YES NO

4. Does your child suffer from?

a) Epilepsy YES NO

b) Diabetes . .. . YES NO

c) Asthma YES NO

d) Bedwetting . . . YES NO

e) Allergies . YES NO

5. Has there been any serious illness in the last three-months? YES NO

6. Are there any restrictions upon physical activities? YES NO

Has your child received an anti-tetanus injection? If yes give date.

I hereby give permission for my child to receive proprietary medication, as appropriate for a person of their age, if deemed necessary. I agree to. my. child receiving medication as instructed and any emergency dental, medical or surgical treatment including anaesthetic or blood transfusion, as considered necessary by the medical authorities. I declare that I have answered all the above questions to be best of my ability and have not knowingly- withheld any information regarding physical fitness.

Date

(Person with Parental Responsibility sign and print name)

This medical form, when completed by a person with. parental responsibility, must be returned to the school, the teacher or leader in charge will take the completed form on the visit. For visits to the County Outdoor Education Centres it will be handed in to the Centre Manager upon arrival.

   I give permission for my child to attend the Outdoor Education Course at Coven Outdoor Education centre.

   I enclose a cheque for £67 made payable to STAFFORDSHIRE COUNTY COUNCIL

   I qualify for Income Based Job Seekers Allowance, support under Part 6 of the Immigration and asylum Act 1999, Child Tax Credit, or Invalid Care Allowance (Delete as appropriate)