ROOKS HEATH COLLEGE for Business & Enterprise
FORM OF CONSENT FORM EV8
PROPOSED ACTIVITY: _______________________________________________________
This form must be returned at least a week prior to the activity if the student is to be allowed to participate.
Student’s surname Date of Birth
Forenames Tutor group
Full postal address
Postcode Telephone number
Emergency telephone number Name of contact
1. Medical details
Does the student suffer from any condition which may cause her/him problems during the journey or
whilst away from home? If Yes, please give details below.
2. Does the student have a regular requirement for medication? If Yes please give details.
3. Student’s doctor is: Dr.
Address of doctor:
Telephone number of Doctor:
I , (print name) being the person with parental responsibility
of the above named student, hereby consent to her/him being a member of the above named educational
activity. I have read and understood the notes sent out in any letters or other literature sent out with regard
to this activity, including the fact that s/he will be participating in adventurous activities*.
I confirm that, in the case of a student with an ongoing medical condition described in 1 or 2 above, the
GP has passed my child fit to participate in the proposed activities.
I consent to the provision of any emergency medical treatment, if necessary.
I consent to the use of the following on my child if the person in charge of first aid deems it necessary:
medicines named in 2 above*, sun cream*, Paracetomol*, travel sickness tablets*
*Delete as necessary
4. Health or Religious dietary needs:
Signed (Person with parental responsibility) Date
If any of the information above changes prior to the activity, please inform the school office in
writing as soon as possible.
This version: 20/10/2006