Camp Consent Form

Room 23’s
Berwick Camp
th
th
8 – 12 August
Please fill in this form and return to class teacher
This form is confidential to camp teachers.
Pupil’s Name: _______________________________________ Class Number: ______________
Parent / Guardian Information:
Name: ___________________________________________ Home Phone No: ______________
Address: _________________________________________ Work Phone No: ______________
_________________________________________
Additional Emergency Contact:
Name:____________________________________________

Phone No:_______________

Relationship:_______________________________________ (e.g. neighbour, grandparent)
Family Doctor:______________________________________

Phone No: _______________

Trip

I approve of my child attending this trip.

In the event of illness or accident I authorise such medical assistance as maybe necessary.

I agree that my child should take part in those activities and duties required by staff.

I understand that this is a school trip and that school rules apply.

In the event of a serious breach of discipline I agree that my child may be withdrawn from the trip.

Medical

Please complete the attached medical sheet which will give us a detailed summary of health
considerations for your child.

Has your child had a course of anti-tetanus injections? YES / NO

Date of last injection: ___________________________
Signature of Parent or Guardian: ___________________________ Date: ______________
Staff Check: _______

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