We will be meeting in the Iceland Car Park at 6pm on Friday and returning to the same

place on Tuesday at approximately 2:30pm. Please fill in this form regardless of

whether or not you are over 18 as we will still need emergency contacts and medical
details. Thank you.
Name: ___________________________________________________________________
Age: __________________________ D.O.B. ____________________________________
Address:
_________________________________________________________________________
To be filled in by parents of under 18s only:
I give permission for ___________________ to participate in Summer Madness and all its
activities and confirm that he/she is willing to participate as fully as possible.
I permit my child to travel in either private vehicles or any other transport that has been
designated official for the purposes of this event: YES/NO
Signature___________________________ Relationship to Child
__________________

Health and Safety

(All information is confidential and should be as detailed as possible.)

GP Name___________________________ GP Telephone Number __________________

Emergency Contact 1

Emergency Contact 1

Name: ____________________________

Name: _________________________________

Address:
_________________________________
_________________________________

Address:
_______________________________________
_______________________________________

Relationship to Child: ________________

Relationship to Child: _____________________

Telephone Number (Home)

_________________________________

Telephone Number (Home)

_______________________________________

Telephone Number (Work/Mobile)

_________________________________

Telephone Number (Work/Mobile)

_______________________________________

Medical Details

(Over 18s are required to fill in this part of the form but do not need a
parents signature at the bottom, anybody under 18 requires the signature of a parent/guardian at
the bottom of this section.)

Does he/she suffer from any medical conditions?

YES / NO

Is YES please give details _____________________________________________________

Does he/she suffer from any allergies?

YES/NO

If YES please list and detail any related medicines or inhalers used
___________________________________________________________________________
Is he/she taking any medication / treatment?

YES/NO

Please Detail ________________________________________________________________

(Please make sure participant has sufficient medication with them)
In the unlikely case of an emergency it is important to know if he/she can take:
Paracetamol:

YES / NO

Panadol:

YES / NO

Has he/she had any adverse reaction to an anaesthetic?

Aspirin:

YES / NO

YES / NO

If YES please give details or any other relevant information

____________________________________________________________________________
In the case of an emergency leaders will do everything possible to contact the parents so that
they can make the appropriate medical decisions for their child. In extreme circumstances
where medical treatment is required without delay and it has been impossible to contact those
named on the health form, I authorise the certified first aider and/or the leader in charge to give
consent for any medical treatment on my/our behalf.
YES / NO
Signed (parent/guardian) _______________________________________________________

Consent for the use of Photographs or Video

Drumglass Parish and Vineyard Church Dungannon recognise the need to insure the welfare
and safety of all young people. In accordance with our child protection policy we will not permit
photographs, videos or other images of young people to be taken without the consent of the
parents/guardians.
(For under 18s)

I consent to my child having their photograph taken child for the purpose of Summer Madness:
Signed _______________________________________________ Date __________________
(Over 18s)

I consent to having my involvement in Summer Madness being photographed:

Signed _______________________________________________ Date __________________