QE2 Activity Centre

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 don’t mind having my picture taken           c I don’t want to have my picture taken