Medical consent form KAO2013

To be completed in respect of a child under 16 by a parent.

Please ensure this form is completed and brought to registration Children will not be admitted to the event without this signed/completed form.

The Salvation Army will use your/your child’s information for providing services and will process this sensitive data accordingly. By signing this form you consent to our keeping such records on file during and for a period of 6 months after the event and using them for the above purposes. The information will be stored securely and confidentially at DHQ/THQ. You have a right to ask for a copy of the information and correct any inaccuracies

Child’s Surname

First Name

Date of Birth

Address

GP’s Name

GP’s Phone No.

GP’s Address

Does your child suffer with any medical or psychiatric condition?

Yes No If yes, please give details

Does your child have any of the following conditions? Please give any further details as required

Epilepsy

Yes

No

Diabetes

Yes No

Asthma

Yes No

Anaphylaxis

Yes No

Date of last tetanus injection

Is your child up to date with all childhood immunisations?

Yes No Is your child allergic to anything (eg medicine, stings, nuts, etc.) or have any phobias or fears that it may be helpful for leaders to be aware of?

Yes No

If yes, please give details:

Does your child have any special dietary requirements? Please give details: Please Note: If you did not provide this information on the booking form please email details to graham.slader@salvationarmy.org.uk immediately so St Mark’s College can be advised

I agree to my child (under 16) being given the following medicine: (please tick as appropriate)

Paracetamol

Ibuprofen

Throat lozenges

Insect bite relief

Plasters

Antiseptic cream

Has your child been in contact with any infectious diseases within the past three weeks?

Yes No If YES, please give details:

Is your child receiving any medical or psychiatric treatment at present?

Yes No If yes, please give details

Is your child taking any prescribed medication that will need to be administered during the event? Yes No Would you like us to administer that medication? Yes No

If No please be aware that your child must ensure their medication is stored safely (preferably in a locked container) and cannot be taken by other children If Yes, please ensure that this section is completed as consent for us to administer medicine to your child on your behalf: Name of medication as described on the container: What is it for? For how long will your child need this medication? Date dispensed: Expiry date: Full directions for use and storage: Dosage and method of administration (by mouth, inhaled etc) Times to be taken: Special precautions: Side effects: Procedures to be taken in an emergency:

For all children, please give details of two people who should be contacted in an emergency:

Name Name

Relation

Relation

Address Address

Contact phone number

Contact Phone number

If emergency medical treatment is needed, do you give consent for this to be carried out according to the best judgement of any medical staff who may attend your child/you? I give my consent for emergency treatment to be given if necessary:

Signed

(Parent / Guardian)

I give my consent for emergency anaesthetic to be administered if necessary:

Signed

(Parent / Guardian)

Please indicate whether you have parental responsibility for the child named above:

Yes No

Activity Consent Form KAO2013

Do you give your consent for your child to take part in the following activities being run by St Mark’s College?

‘It’s a Knockout’ style games

Yes

No

Initiative Team Games

Yes

No

(Please see www.stmarkscollege.co.uk/activities for more information) I understand that photographs and videos may be taken of my child during the event that may later be used in publicity material (ie printed publications (eg Kids Alive!, promotional leaflets), DVD, Website)

Do you give your consent for the use of your child’s unnamed image?

Yes

No

Please read the following code of conduct and sign the consent form below as agreement both to the above and the code of conduct

Code of Conduct This Code of Conduct has been put together so that all children and staff can take responsibility for their behaviour during KAO, with the understanding and support of the parents. Please take time before KAO to share this with your child so that they are aware of what is expected.

We ask all children:

To treat everyone involved in the event with respect at all times regardless of age, race, ability or gender

To follow the request that no mobile telephones, laptops or other electronic equipment should be brought to KAO.

To show respect for St Mark’s College property by keeping rooms clean and tidy, not eating food in bedrooms, using litter bins provided and reporting any damage to the staff.

To abide by the instructions given regarding out-of-bounds areas. Not to publish any photos taken at KAO (not every parent will have given permission for their

child’s photo to be taken). Never to use equipment or an activity area unless a member of staff is present.

Please understand the following: If a young person is posing a danger to themselves or others by their behaviour (including

bullying), arrangements will be made for them to go home. KAO adopts the Safe & Sound Counter Bullying Policy

For the sake of the whole group we ask all young people not to behave in a way or to bring material, that is inappropriate to the age of the young people at KAO (ages 7-12 years).

Staff are also asked to sign a code of conduct for the event. For your knowledge, this includes an agreement that:

They will work according to Safe & Sound and Safe from Home policies at all times There will always be at least two adults with a group of young people They will not make personal social contact with the young person outside the context of the

activities Should any staff member wish to keep in contact with a young person after KAO it will be with

parent’s knowledge and consent, and through the DHQ office

Signature of young person Date

Name of parent / guardian

Name of signatory (parent / guardian) Date

Please indicate whether you have parental responsibility for the child named above:

Yes No