Child's Name *

First Name

Last Name

Parent/Guardian Name *

First Name

Last Name

Has the above named child ever had a reaction to penicillin? *

If yes, please give details below.

Yes

No

Does he/she suffer from any allergies? *

Yes

No

Does he/she carry any medication that needs to be taken regularly? *

Yes

No

Does he/she suffer from a medical condition or illness requiring regular treatment? *

Yes

No

In an emergency and/or you are not contactable are you willing for your child to receive doctor or hospital treatment including anaesthetic? *

Yes

No

Consent *

I agree that the above named child may take part in the group above and related activities organised by St. Swithin’s Church including any organised trips. I understand that while involved, he/she will be under the control and care of the group leader, and/or other adults approved by the PCC, and that, while the staff in charge of the group will take all reasonable care of the children, they cannot necessarily be held responsible for any loss, damage or injury suffered by my child during, or as a result of, the activity. I agree to this information being stored and kept on file. (It will be kept confidential but may be used in an emergency to give information to medics etc).

Yes

No

The above named child may be photographed/filmed for external use (e.g. local newspaper etc) *

Yes

No

The above named child may be photographed/filmed for church use & publicity. *

Yes

No

The above named child has permission to go to and from groups or activities unaccompanied. *

Yes

No