Get documents about "Parental Consent for Medical Treatment Form
Description
Parental Consent for Medical Treatment Form document sample
Document Sample
Please complete this workbook, you will find it works better if you fill in the spreadsheets in order starting with "Memb
Please note that the membership type drop down box needs to be used to select the rate -particularly important to ge
When you have finished:
1 Email the completed workbook back to dee@lindesay.co.uk
2 Print, check and sign the Summary Sheet (and Parental Consent)
3 Send the summary sheet (and any documents indicated on it)
with your cheque payable to Shepperton Slalom Canoe Club to
Dee Lindesay
6 Oaklands Drive
Ascot
Berks
SL5 7NE
I will acknowledge receipt by email when I have both parts, but please give me a few days!
he spreadsheets in order starting with "MembershipApplication".
o select the rate -particularly important to get the much cheaper junior rate!
SSCC Membership Application 2010
PERSONAL DETAILS
First Name(s) Surname Member Type
Address Post Code
Gender Home Telephone BCU Member NRA River Licence N
Date of Birth 25 Mobile BCU Number
Age Category 2010 S Email Expiry Date FALSE
Please tick box if you do not want your details circulated to club members Home Telephone E mail Mobile
Please tick box if you do not consent to images of you participating in SSSC activities being used for club pubilicity including on the Club's website
SLALOM RANKING
Kayak Division Bib 2010
C1 Division Bib 2010
C2 Division Bib 2010 Partner
C2 Division Bib 2010 Partner
QUALIFICATIONS
Paddle Power Awards New Style BCU Awards Old Style BCU Awards
PP Combined Kayak
WW Kayak Canadian
Touring
Open Canoe
Surf
Sea Kayak
New Style Coaching Awards Old Style Coaching Awards
Boat Based Slalom
Bank Based WWR
CCK
Safety Training Child Protection Other
Year Year
CST CP Course First Aid Expiry Dt
FSR CRB Check Other
WWSR
AWWSR
RELEVANT MEDICAL CONDITIONS
Medical conditions (for example Allergies, Asthma, Diabetes, Epilepsy etc) is confidential and will only be available to club instructors and
relevant club officers
EMERGENCY CONTACT
Name Telephone Mobile
Additonal Family Member 1- 2010 Main Member Type
PERSONAL DETAILS
First Name(s) Surname Member Type
Address Post Code
Gender m Home Telephone BCU Member N NRA River Licence N
Date of Birth 25 Mobile BCU Number
Age Category 2010 S Email Expiry Date FALSE
Please tick box if you do not want your details circulated to club members Home Telephone E mail Mobile
Please tick box if you do not consent to images of you participating in SSSC activities being used for club pubilicity including on the Club's website
SLALOM RANKING
Kayak Division Bib 2010
C1 Division Bib 2010
C2 Division Bib 2010 Partner
C2 Division Bib 2010 Partner
QUALIFICATIONS
Paddle Power Awards New Style BCU Awards Old Style BCU Awards
PP Combined Kayak
WW Kayak Canadian
Touring
Open Canoe
Surf
Sea Kayak
New Style Coaching Awards Old Style Coaching Awards
Boat Based Slalom
Bank Based WWR
CCK
Safety Training Child Protection Other
Year Year
CST CP Course First Aid Expiry Dt
FSR CRB Check Other
WWSR
AWWSR
RELEVANT MEDICAL CONDITIONS
Medical conditions (for example Allergies, Asthma, Diabetes, Epilepsy etc) is confidential and will only be available to club instructors and
relevant club officers
EMERGENCY CONTACT
Name Telephone Mobile
Additonal Family Member 2- 2010 Main Member Type
PERSONAL DETAILS
First Name(s) Surname Member Type
Address Post Code
Gender m Home Telephone BCU Member N NRA River Licence N
Date of Birth 25 Mobile BCU Number
Age Category 2010 S Email Expiry Date FALSE
Please tick box if you do not want your details circulated to club members Home Telephone E mail Mobile
Please tick box if you do not consent to images of you participating in SSSC activities being used for club pubilicity including on the Club's website
SLALOM RANKING
Kayak Division Bib 2010
C1 Division Bib 2010
C2 Division Bib 2010 Partner
C2 Division Bib 2010 Partner
QUALIFICATIONS
Paddle Power Awards New Style BCU Awards Old Style BCU Awards
PP Combined Kayak
WW Kayak Canadian
Touring
Open Canoe
Surf
Sea Kayak
New Style Coaching Awards Old Style Coaching Awards
Boat Based Slalom
Bank Based WWR
CCK
Safety Training Child Protection Other
Year Year
CST CP Course First Aid Expiry Dt
FSR CRB Check Other
WWSR
AWWSR
RELEVANT MEDICAL CONDITIONS
Medical conditions (for example Allergies, Asthma, Diabetes, Epilepsy etc) is confidential and will only be available to club instructors and
relevant club officers
EMERGENCY CONTACT
Name Telephone Mobile
Additonal Family Member 3- 2010 Main Member Type
PERSONAL DETAILS
First Name(s) Surname Member Type
Address Post Code
Gender m Home Telephone BCU Member N NRA River Licence N
Date of Birth 25 Mobile BCU Number
Age Category 2010 S Email Expiry Date FALSE
Please tick box if you do not want your details circulated to club members Home Telephone E mail Mobile
Please tick box if you do not consent to images of you participating in SSSC activities being used for club pubilicity including on the Club's website
SLALOM RANKING
Kayak Division Bib 2010
C1 Division Bib 2010
C2 Division Bib 2010 Partner
C2 Division Bib 2010 Partner
QUALIFICATIONS
Paddle Power Awards New Style BCU Awards Old Style BCU Awards
PP Combined Kayak
WW Kayak Canadian
Touring
Open Canoe
Surf
Sea Kayak
New Style Coaching Awards Old Style Coaching Awards
Boat Based Slalom
Bank Based WWR
CCK
Safety Training Child Protection Other
Year Year
CST CP Course First Aid Expiry Dt
FSR CRB Check Other
WWSR
AWWSR
RELEVANT MEDICAL CONDITIONS
Medical conditions (for example Allergies, Asthma, Diabetes, Epilepsy etc) is confidential and will only be available to club instructors and
relevant club officers
EMERGENCY CONTACT
Name Telephone Mobile
Additonal Family Member 4- 2010 Main Member Type
PERSONAL DETAILS
First Name(s) Surname Member Type
Address Post Code
Gender m Home Telephone BCU Member N NRA River Licence N
Date of Birth 25 Mobile BCU Number
Age Category 2010 S Email Expiry Date FALSE
Please tick box if you do not want your details circulated to club members Home Telephone E mail Mobile
Please tick box if you do not consent to images of you participating in SSSC activities being used for club pubilicity including on the Club's website
SLALOM RANKING
Kayak Division Bib 2010
C1 Division Bib 2010
C2 Division Bib 2010 Partner
C2 Division Bib 2010 Partner
QUALIFICATIONS
Paddle Power Awards New Style BCU Awards Old Style BCU Awards
PP Combined Kayak
WW Kayak Canadian
Touring
Open Canoe
Surf
Sea Kayak
New Style Coaching Awards Old Style Coaching Awards
Boat Based Slalom
Bank Based WWR
CCK
Safety Training Child Protection Other
Year Year
CST CP Course First Aid Expiry Dt
FSR CRB Check Other
WWSR
AWWSR
RELEVANT MEDICAL CONDITIONS
Medical conditions (for example Allergies, Asthma, Diabetes, Epilepsy etc) is confidential and will only be available to club instructors and
relevant club officers
EMERGENCY CONTACT
Name Telephone Mobile
Boat Rack Application - 2010
£30 per rack
Current Rack Current Rack
Member Boat Type Frequency of Use Special Needs
Holder Number
New Key Request - 2010
You will need a key and fob to access the club house.
If you pay for a boat rack you will get access to the boat shed with your key.
Please return any unwanted keys/fobs to get your money back!
Deposit Number Required Cost
New Key £15 £0
Fob £5 £0
£0
Member Name Membership BCU NRA Racks Keys Total
Shepperton Slalom Canoe Club will take care is taken to ensure your safety during Club activities. However, Canoeing and Kayaking are ‘assumed risk’ – ‘water contact sports’ that
may carry attendant risks. Participants should be aware of and understand these risks, and be responsible for their own actions and involvement. Public Liability is covered by our
Affiliation to the British Canoe Union. Details of Public Liability insurance cover is given on www.bcu.org.uk
I agree that I have read and understood the paddler’s guide, the rules of the Club and the Constitution and that I agree to abide by them.
Data Protection: I agree to information being held by Shepperton Slalom Canoe Club and used for Club administration and to keep me informed of Club activities. The Club will
not share your details with third parties without your permission. This data may be kept electronically.
I consent to the Home Telephone Number, Email Address and Mobile Number for me/my child being distributed to other club members. I do consent to images of me/my child
participating in Shepperton Slalom Canoe Club activities being used for club publicity, including on the Club’s website.
Signature of Applicant(s), (Parent/Guardian if under 18) Date: ___________________
_________________________________________
PARENT’S CONSENT FORM 2010
I wish my son/daughter ___________________________to be allowed to take part in the following Shepperton
Slalom Canoe Club activies
Please tick the appropriate boxes to indicate which activities you are agreeing to him/her taking part in:
o Training and fun sessions under the supervision of experienced paddlers or qualified coaches on the Thames
o Moving water training at Shepperton Weir
I have ensured that my child(ren) understand(s) that it is important for his/her safety and for the safety of the
group that any rules and any instructions given by the coaches in charge are obeyed instantly.
My child(ren) can swim 50 metres in light clothing Yes o
Family Doctor Doctor’s Tel No
I confirm to the best of my knowledge that my son/daughter does not suffer from any medical condition other than
those listed. In your child’s interest, it is important that the organising staff should know whether he or she suffers
from any illness or medical condition. Please use the space below to state in confidence any health or other matter
concerning your child or which accompanying club members should be aware. Please also indicate if your child is
receiving medication, with details and dosage .
Please state medical condition and/or medication
Please read carefully:
I have had the activities of the club explained and agree to my son/daughter taking part in these activities.
I consent to my child receiving medical treatment, which, in the opinion of a qualified medical practitioner,
may be necessary.
I consent that photographs taken by authorised personnel of my son/daughter at BCU or Club events may be
used to promote paddlesport and confirm that my son/daughter is not subject to any court order prohibiting
publication of their image
I consent to my son/daughter travelling by any form of public transport, minibus or motor vehicle driven by a
club coach or any other parent attending, to any event in which the club is participating.
I agree to be at the pick-up/drop-off point at the agreed time.
I understand that the Club or Organisers accept no responsibility for loss, damage or injury caused by or during
attendance on any of the Club’s organised activities except where such loss, damage or injury can be shown to
result directly from the negligence of the Club or Organisers.
Signed (Parent/Guardian) Date: 04-Mar-2011
Emergency Contact Person and Phone Number:
Please note that the above information is not published to all Club members.
Canoeing and Kayaking are ‘assumed risk’ – ‘water contact sports’ that may carry attendant risks.
Participants should be aware of and understand these risks, and be responsible for their own actions
and involvement.
