WESSEX ORIENTEERING CLUB

PARENTAL CONSENT AND MEDICAL DATA FORM.

Course Venue and Date………………………………………………………………..

Participant’s Full Name…………………………………………………………………………

Date of Birth………………………………………………………………………………….……

Address………………………………………………………………………………………….…

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Name and Contact address of Next of Kin…………………………………………………….

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Tel……………………………………………………………………………………….………….

Name and Contact address of Doctor………………………………………………………….

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Tel………………………………………………………………………………………………...…

Any medical disabilities, treatment, medication, allergies or any other relevant information? (e.g. must carry inhaler at all times, takes tablets daily, hay fever sufferer etc.)………………………………………………………………………………………………..

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Any Special Dietary requirements?....................................................................................

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I acknowledge receipt of, and understand, all of the published information regarding the proposed activity/visit as outlined above and consent to the participation of:

…………………………………………………………………………………………………….

I have ensured that my son/daughter understands the information for his/her safety and for the safety of the group and that any rules and instructions given by staff are obeyed.

I undertake to inform the leader of any changes in his/her medical health or fitness prior to the date of departure/commencement of activity.. I am in agreement that those in charge may give permission, including written, for the participant mentioned above to receive medical/dental treatment in an emergency.

Signed (Parent/Guardian)……………………………………………..Date……………………….

I understand that for the group and my own safety I will undertake to obey the rules and instructions of members of staff.

Signed (Under 18)…………………………………………………..Date……………………………..