2012 CONSENT FORM
NAME OF PARTICIPANT ........................................... DATE OF VISIT
NAME OF GROUP ...........................................
ADDRESS ............................................ AGE IF UNDER 18
............................................ if you are over 18 are you
............................................ 18-35 35-50 50-65 over 65
TELEPHONE ............................................ (please circle)
EMERGENCY CONTACT
NAME ..................................................
RELATIONSHIP ..................................................
ADDRESS .................................................. .
TELEPHONE ................................................(day) ........................................(evening)
MOBILE ................................................
Details of swimming ability/water confidence (eg 25m /50 m /water confident) ...............................................
Please note that ability to swim is NOT essential for water based activities
MEDICAL INFORMATION
Are you currently receiving medical treatment? yes/no
If yes please give brief details
Have you been given specific medical advice to follow in an emergency? yes/no
If yes please give details
Do you have any allergies to food or medicine which we should be aware of? yes/no
If yes please give details
Please give details of disability, illness or injury below
cadhd casthma cautism spectrum condition
caxial instability cbronchitis cchallenging behaviour
cdiabetes cepilepsy cfits or fainting
cheart condition clearning disability cmuscle weakness
cphysical disability csensory impairment cother (please specify)
CONSENT
I have given full medical details. I consider that I am capable of participating in the activities organised by the Centre. In the event of illness or accident I give my consent to any necessary medical treatment.
Signed ............................................... (participant over 18)
Signed ............................................... (parent/guardian if participant under 18)
We sometimes take photographs for educational or display purposes
c I dont mind having my picture taken c I dont want to have my picture taken