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Form PCB - DOC by yoursovain

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									                                          Form PC/B
                                 The Duke of Edinburgh’s Award
               Personal Information and Parental Consent Form for Expeditions
       Costessey Youth and Community Centre, 38 Breckland Road, New Costessey, Norwich NR5 0RW
              Tel: 01603 744888 Fax: 01603 744999 Email: alan.alderton@norfolk.gov.uk

The Visit Leader will only divulge information on this form to other staff as necessary, to ensure the
welfare and safety of the participant.
 TRAINING – from the beginning – for novice campers.
 PRACTICE – before attending the practice weekend you should have your training signed up.
 ASSESSMENT – before assessment you should have completed and had signed up your training and practice.
 Please tell us about previous relevant experience/awards gained, with dates ……………………………………….
 …………………………………………………………………………………………………………………………………
 PLEASE CIRCLE THE LEVEL YOU REQUIRE, BRONZE OR SILVER, SELECT THE DATE YOU REQUIRE
 AND SELECT TRAINING, PRACTICE OR ASSESSMENT.
 BRONZE – TRAINING PRACTICE ASSESSMENT
 SILVER – TRAINING PRACTICE                                                                         £25.00
                  th                     st
 1)    Friday 30 March to Sunday 1 April 2007                                                 Trimingham
                  th                    nd
 2)    Friday 20 April to Sunday 22 April 2007                                                   Seething
                th                 th
 3)    Friday 4 May to Sunday 6 May 2007                                                               Holt
                  th                   th
 4)    Friday 25 May to Sunday 27 May 2007                                                     Theberton
                  th                  st
 5)    Friday 29 June to Sunday 1 July 2007                                             Thorpe Woodlands
                                       th
 6)    Friday13th July to Sunday 15 July 2007                                                    Ilketshall
                  th                           th
 7)    Friday 28 September to Sunday 30 September 2007                                           Seething
                  th                        st
 8)    Friday 19 October to Sunday 21 October 2007                                             Theberton

 SILVER – ASSESSMENT (Please select date you require)                                                     £40.00
              th                th
 4S) Friday 25 May to Monday 28 May 2007                                                               Theberton
              th               nd
 5S) Friday 29 June to Monday 2 July 2007                                                       Thorpe Woodlands
              th                   nd
 8S) Friday 19 October to Monday 22 October 2007                                                       Theberton

 GOLD
 All candidates planning to join one of the gold wild country weeks must attend the local preparation weekend,
 the cost of which is included in the £150.00.
 WILD COUNTRY PREPARATION WEEKEND
                 nd                     th
 9)     Friday 22 June to Sunday 24 June 2007                                                Thorpe Woodlands
 PLEASE INDICATE PRACTICE OR ASSESSMENT
                   nd                      th
 10) Sunday 22 July to Saturday 28 July 2007                                                             Wales
                  th                          th
 11) Tuesday 7 August to Monday 13 August 2007                                                         Wales ?
                     th                      th
 12) Saturday 18 August to Friday 24 August 2007                                                   Peak District

Participant’s full name: ………………………………………………………... Male/Female: ……………………………
Date of Birth: ………………… Age at Date of Expedition: …….. School/Group: ……………………………………
Home Address: …………………………………………………………………………………………………………………
…………………………………………… Post Code: ………………… Main Telephone No: ………………………….
Next of Kin and essential emergency contact information for course duration.
Who can collect your young person if they are ill?
Please note that in the unlikely event that a participant’s behaviour is inappropriate to the point of requiring their
removal from the expedition, the person named below will be contacted and expected to collect the young person.

(i)     Name: ……………………………………… Address: ………………………………………………………………..
        ………………………………………………………. Tel No: ……………………                                         Relationship: ………………
(ii)    Name: …………………………………….. Address: …………………………………………………………………
        ………………………………………………………. Tel No: ……………………                                         Relationship: ………………
                                                                                                     Continued over/
NAME OF PARTICIPANT: ……………………………………………………………………………………………………
Doctor’s Name: ……………………………….. Doctor’s Tel No: …………………. NHS No (if known): …………….
Date of last known tetanus injection (if known): …………………………………………………………………………….
Please give details of any recent illnesses: …………………………………………………………………………………
……………………………………………………………………………………………………………………………………..
Please give name and dosage of any medications currently being taken: ………………………………………….…..
……………………………………………………………………………………………………………………………………..
Please tell us about any allergies, e.g. medicines, food, bee stings, etc: …………………………………………….….
……………………………………………………………………………………………………………………………………..
Please tell us about any food not eaten for religious or health reasons: …………………………………………………
Please provide any other information which you feel might be useful in an emergency, or that the Visit Leader
should be aware of: e.g. phobias, epilepsy, hyperventilation, sleepwalking, diabetes, travel sickness, toileting
difficulties, friendship problems, etc: ………………………………………………………………………………………….
……………………………………………………………………………………………………………………………………..
I am willing for my child to take part in the above expedition and having read all the information provided, I agree
to his/her taking part in the activities described.

I fully understand and accept that, whilst the supervisory adults in charge of the group will take all reasonable care
of the young people, neither they, nor Norfolk County Council, can necessarily be held liable in respect of loss or
damage to property or injury suffered by my child arising out of the expedition, unless such loss, damage or injury
results from the negligence of Norfolk County Council, its employees or official volunteers.

Please tick box if permission given for photographs and/or video footage to be taken.

Please tick box if permission given to receive pain relieving medication when appropriate
(one dosage of paracetamol only).

I agree to my child/ward receiving medication as instructed and any emergency dental, medical or surgical
treatment, including anaesthetic or blood transfusion, as considered necessary by the medical authorities present.

Where young people need to be transported during the expedition it will be by minibus with seatbelts.

I understand the extent and limitations of the insurance cover provided.

Signature of Parent / Guardian (if participant is under 18): ………………………………………………………………..

I agree that I shall be a member of the stated course and that I shall be subject to the authority, guidance and
discipline of the staff.

Signature of Participant: ……………………………………………………………………………………………………….
Should there be any amendments to this form after it has been handed in, please contact the Visit Leader
immediately.

This information will be held in accordance with the 1998 Data Protection Act. Names and emergency
contact numbers will be shared with persons responsible for safety and emergency procedures for the
duration of the visit and then destroyed.

PAYMENT
If you are attending the expedition with a school group, please make your cheque payable to the school and take it
with the form to the school. (They will then transfer the money to us electronically).

If you are sending the form directly to this office, please make the cheque payable to Norfolk County Council.

								
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