Medical and Consent form

MEDICAL AND CONSENT FORM

The Prince’s Trust programmes involve a range of activities, which will be conducted safely and to the highest possible standards. It is important that we know about any
medical conditions and that you give consent to take part in programme activities. The Prince’s Trust believes in equality of opportunity and will make every effort to make
sure young people with medical conditions can take part in our programmes.
Please complete the following form in full.

YOUR DETAILS

First name: Ana-Maria-catalina Surname: Karagounis

Address: 1 the Chatham, Thorn walk Postcode: Rg1 7bj
Phone number: 07900107650 Date of birth: 8 Dec 1996 Gender: Female

DOCTOR’S DETAILS

Are you registered with a doctor? ■

Yes No Doctor’s full name: University medical group
Doctor’s address: 9 North court avenue, Reading
Postcode: Rg2 7he Doctor’s phone number:

MEDICAL DETAILS

Do you have any allergies? Yes ■

No Do you have epilepsy or any
other neurological disorder? Yes ■
No
Details:
Details:

Do you have any dietary requirements? Yes ■

No
Details: Do you have Hepatitis, HIV
or any other blood disorder? Yes ■ No
Details:
Do you have diabetes (Type 1 or Type 2)? Yes ■
No
Details:
Are you or could you be pregnant? Yes ■ No

Do you have asthma Do you have any recent/ongoing

or any breathing conditions? Yes ■
No dental issues? Yes ■
No
Details: Details:

Do you have a heart condition Have you attended hospital in the

or any circulatory problems? Yes ■
No last two years for injury/illness? Yes ■
No
Details: Details:

Do you have any joint Are you affected by any mental health conditions?
or muscle difficulties? Yes ■
No (e.g. schizophrenia, ADHD, depression) Yes ■
No
Details: Details:

Please tell us about any other information you think we should know, including any disabilities or known medical conditions you have:

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 PRESCRIBED MEDICATIONS

Please give us details of any medication that your doctor has given you and you are currently using:

Name of medication: Dosage:

Reason for use:

Name of medication: Dosage:

Reason for use:

Name of medication: Dosage:

Reason for use:

Name of medication: Dosage:

Reason for use:

Name of medication: Dosage:

Reason for use:

NEXT OF KIN DETAILS This is the person we will contact in an emergency

First name: Konstantinos Surname: Karagounis

Relationship to young person: Husband
Address: 1 the Chatham, thorn walk, reading
Postcode: Rg1 7bj
Home phone number: Mobile phone number: +44 7938 963929

CONSENT

I agree that the medical and next of kin information given on this form is correct
and can be used by The Prince’s Trust to protect my health and safety whilst I am
on the programme. I agree to The Prince’s Trust storing any prescribed medication
to aid safe usage whilst I am on the programme and to receive general First Aid
and emergency medical treatment, including blood transfusion and/ or anaesthetic,
as considered necessary by a trained First Aider or the medical authorities present.
I understand that paracetamol can be provided as part of First Aid provision.
Please tick here if you do not wish paracetamol to be provided.
I understand that, during my time with The Prince’s Trust, I may participate in
adventurous activities. I am aware that participation in the activities organised
may expose me to certain risks. I fully understand and accept the risks and give
my consent to participate.
The medical and next of kin information on this form will be treated as confidential
and shared only with programme staff and medical authorities and in accordance
with GDPR 2018 and the Data Protection Act 2018. I understand that this
information will be destroyed within three months of me leaving the programme
(including any post-programme support). I also understand that I will take part in
evaluation activities as an embedded part of the programme in order to run, fund and
evaluate The Prince’s Trust programmes.
Information held about me by The Prince’s Trust can be used by the Trust and shared
with other organisations working with them, to help run, fund and evaluate The Trust’s
programmes and for the benefit of my welfare, safeguarding and future journey. The
Trust will keep my information no longer than is required to satisfy legal and
regulatory requirements and to assist The Trust to help me through my journey with
The Trust. I consent to the use of my data for the purpose above ✔
I understand I have the right to ask to see information held about me by The
Trust. For further information about how the Trust uses your data, I can read the full
privacy statement available at princes-trust.org.uk or ask a member of staff. I
understand that I may withdraw consent to the processing of my data at any time, and
this may be done by contacting my Programme Executive or 0800 842 842.
I consent to the use of my data for the purpose above ✔

Young person name: Ana-Maria-Catalina Karagounis Date: 21 July 2021

Signature: Karagounis

Parent/Guardian name: Date:

Relationship to young person:

Signature:

DSN 3158-7-A4 © The Prince’s Trust 2018 – all rights reserved. The Prince’s Trust is a registered charity, incorporated by Royal Charter (RC000772). Principal office: The Prince’s Trust South London Centre, 8 Glade Path, London, SE1
8EG. Registered charity number in England and Wales (1079675) and Scotland (SC041198).

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