FORM – Year 6 Residential Consent and Medical

08/10/2025

Child's Full Name(Required)

First Last

Child's Date of Birth(Required)

Medical Information

Please select any conditions below:

Allergies: including hayfever

Asthma: including seasonal

Diabetes

Epilepsy

Other Conditions: Any other ongoing medical condition that may require medication or specific care during the trip., e.g. sleep problems, nocturnal enuresis (bed wetting).

Condition Medication:(Required)

Are their vaccines up-to-date?(Required)

GP Surgery Name(Required)

GP Surgery Tel.(Required)

Swimming Ability

Is your child water-confident?(Required)

Water-confident is defined as: ability to duck head underwater AND confidently swim 15 metres in a lifejacket or buoyancy aid without signs of panic

Emergency Contact Details

Contact 1(Required)

First Last

Relationship to child(Required)

Mobile Tel. Number(Required)

Contact 2(Required)

First Last

Relationship to child(Required)

Mobile Tel. Number(Required)

Declarartion

Parent/Carer Name(Required)

First Last

Parent/Carer Signature(Required)

Today's Date(Required)