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Grafham Water Consent Form 2021

Does the above person:

• Have a medical condition requiring medical treatment or medication?*
• Have an allergy to certain medications?*
• Is s/he able to administer her/his own medication?
Has s/he received a tetanus injection in the last 5 years?*
Has s/he been in contact with any contagious or infectious diseases or suffered from anything in the last four weeks that may become contagious or infectious?*
Does s/he have any special dietary requirements?*
I confirm that my child is water confident and able to swim 25 metres*

HOME AND EMERGENCY CONTACT INFORMATION
(Must be contactable for the duration of the visit / activity)

FAMILY DOCTOR DETAILS

Declaration by person with parental responsibility for the child/young person.

I am satisfied that all reasonable care will be taken for the safety of those participating and that adequate staffing and safety measures have been arranged*
I understand the extent and limitation of the insurance cover provided.*

I agree that the person named above

can participate in the visit and activities described*
can be transported in the private vehicles of staff/volunteers supervising the visit where necessary*
is in good health and fit to participate in the activities described*
can receive medical treatment as necessary*
I undertake to inform the group leader of any change in medical circumstances prior to the activity date*
I acknowledge the need for the person named above to behave responsibly and agree to the establishment’s procedures in this respect. In the event that their behaviour is not acceptable, I acknowledge that it is my responsibility to make arrangements for them to be collected and cover any associated costs*
I give permission for my child’s photograph to be taken by others and confirm that any pictures taken by my child will be used for personal purposes only and will not be downloaded to the internet or any social networking websites*