Year 6 Residential Consent and Medical Form 08/10/2025 Child's Full Name(Required) First Last Child's Date of Birth(Required)DayDay12345678910111213141516171819202122232425262728293031MonthMonth123456789101112YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Medical InformationPlease 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 AbilityIs 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 panicPlease select...YESNOEmergency Contact DetailsContact 1(Required) First Last Relationship to child(Required)Please select...MotherFatherOtherMobile Tel. Number(Required)Contact 2(Required) First Last Relationship to child(Required)Please select...MotherFatherOtherMobile Tel. Number(Required)DeclarartionConsent(Required)I agree to my son/daughter taking part in the residential school visit to Windmill Hill I agree that he/she is fit enough to take part in the activities listed I acknowledge the need for obedience and responsible behaviour on his/her part. I agree to my son/daughter receiving regular medication as instructed by me in the Medical Information. I agree for a member of school staff to administer to my son/daughter Paracetamol or Piriton in the event of a medical need, e.g. headache, period pain, insect bite. The school will provide Piriton and paracetamol for this need only. I agree to my son/daughter receiving such medical, surgical or dental treatment, including operations under general anaesthetic, as may be recommended by a registered medical or dental practitioner. I hereby authorise the teacher leading the visit or any representative of theirs to sign any written form of consent required by the hospital or Medical Authority, particularly if delay in obtaining my own signature is considered inadvisable by the doctor, surgeon or dentist concerned. I understand that my child is responsible for the safe custody of his/her belongings and effects and that staff cannot be held responsible for them. I agree to the above.Parent/Carer Name(Required) First Last Parent/Carer Signature(Required)Today's Date(Required) DD slash MM slash YYYY
