Longfellow Drive, Worksop, Notts

,
S81 0AW
Tel: or Fax 01909 473743/473955
E mail: office@augustines.notts.sch.uk

I give permission for my child:
Name:…………………...……………….……………………
Class: …………………….

To visit Clumber Park, Friday 8th May 2015
I do/do not require a free packed lunch for my child.
Medical Information
Does your child have Asthma? …………………………………….
Does your child have any allergies?.........................................................
Are there any medical conditions we should be aware of?.....................................................................
Emergency Contact Names & Numbers
………………………………………………………/………………..…………………………………..
Home address
…………………………………………………………………………………………………………….
……………………………………………………………………………………………………………..

Medical Emergencies
In the event of an emergency, we will make every possible effort to contact parents so that prior
consent can be obtained for your child to receive emergency medical treatment as considered
necessary by the medical authorities.
In case we cannot contact you and need to act promptly, please sign to give your consent for
emergency medical treatment including anaesthetic, if necessary.
I / We give consent to our son / daughter receiving emergency medical treatment.
Signed:……………………………………………………. Parent/carer
Date…………………………………