SJF28 – Joint event consent and medical form for

participants aged 17 or under.

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Please complete ALL relevant sections of this form as follows:

Event Organisers: Complete sections: 3a, 3b (if appropriate) & 4a.

Adult with parental responsibility of participants aged 17 or under: Complete sections: 1, 2a, 2b, 3b (consent section if
necessary), 4b, 4c, 5a, 5b, 5c, 5d, 5e, 5f, 6a & 6b.

1. Participant details

Surname: Forename:

Gender: ☐ Male ☐ Female ☐ Other: Date of birth: Age (at event):

Religion: Home telephone no:

Home address (inc postcode): Mobile telephone no:

Email:

Region & District:

Sett / Unit:

2. Emergency contact details

2a. Primary emergency contact details (next of kin) 2b. Alternative emergency contact details
(if primary cannot be contacted)

Surname: Surname:

Forename: Forename:

Home address (inc postcode): Home address (inc postcode):

Home telephone no: Home telephone no:

Mobile telephone no: Mobile telephone no:

Relationship to participant: Relationship to participant:

3a. Principal event details

Title of activity: Braintree Badgers visit to Chelmsford Ambulance Station

Full name and address (inc postcode) of venue: Date from: 24/01/2020 Date to: 24/01/2020
Chelmsford Ambulance Station, Chelmer Valley Rd,
Chelmsford CM1 7FJ

Time from: 18:30 Time to: 20:00

Mode of transport (to and from): Own

SJF28 – Joint event consent and medical form for
participants aged 17 or under.

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3b. Additional event details

Event Location Date Date Time Time Parental

(from) (to) (from) (to) Consent

☐ Yes ☐ No

☐ Yes ☐ No

☐ Yes ☐ No

☐ Yes ☐ No

☐ Yes ☐ No

☐ Yes ☐ No

☐ Yes ☐ No

☐ Yes ☐ No

4a. Outline of programme(s) (include information for ALL relevant activities / events)

4b. Please identify any elements of the programme that you DO NOT wish your child to participate in.
(If you have no concerns then please leave blank).

4c. Please provide details regarding any matters that may affect the participation of any element of the programme
outlined above (i.e. poor swimmer / scared of heights etc)
SJF28 – Joint event consent and medical form for
participants aged 17 or under.

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5. Medical details

5a. Medical History – please give details of all relevant medical history (including any surgery within the last 6 months), or any
on-going medical problems (i.e. asthma)

5b. Medications – please provide details of ALL medications required to be administered during the event.

Name of medication Dose to be taken Times to be taken / how often Other instruction
(Including dosage of (i.e. specific times / 4 x daily / as (i.e. before food, areas for
medications) and when required – if as and when creams, which eye for
req then include max dosage) drops etc.)

5c. ALLERGIES – please list ALL allergies, including the effect the allergen produces and actions to take if required.

5d. Dietary requirements / other health & welfare details – please provide details of ANY dietary requirements or other
matters regarding the participant’s health and welfare that we should be aware of.

5e. Minor ailment medications

In the event of the participant suffering from an illness or injury, I consent to the following medications being offered as needed:

☐ Paracetamol ☐ Ibuprofen ☐ Loratadine

5f. GP details
SJF28 – Joint event consent and medical form for
participants aged 17 or under.

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GP name: GP surgery address (inc postcode):

Surgery telephone no:

Participants NHS number:

Date of participants last tetanus:

6. Consent

6a. Use of photograph or videos (for more information contact the event organiser)

The person with parental responsibility for the participant named in section 1 is to sign here if they approve of the
following statements;

I consent to St John Ambulance (‘SJA’) using photographs, film or audio recordings in which the participant named in Section 1
is featured and/or any quotations provided or case studies about the participant (the ‘Material’) and that the participant may be
identified by name. I understand that this Material may be used to promote SJA campaigns, activities, ways to support SJA
(such as volunteering opportunities and fundraising appeals), events, products, services, youth programmes or information and
know-how, through the following communications:

• Printed promotional or informational materials (e.g. newsletters, direct mail, posters and flyers)
• Digital channels (e.g. social media, websites and emails)
• Media (e.g. broadcast, print and online)
• Advertising (e.g. radio, press, social media and television)
• St John Ambulance internal communications.

I agree that I have no interest in the copyright or any other rights I may have in the Material in which the participant is featured.
I understand that the complete terms of the Privacy Policy are available here: www.sja.org.uk/privacy and that I may withdraw
my consent to the use of the Material at any time by contacting the Data Protection Officer by e-mail at
dataprotection@sja.org.uk or by post at 27 St John's Lane, London EC1M 4BU.

Name: Date:

Signed:

6b. Event activity & medical consent for a participant aged 17 or under

The person with parental responsibility for the participant is to sign here if they approve of the following statements;

• I confirm that I have parental responsibility for the participant

• I confirm that the details given on this form are complete and correct to the best of my knowledge
• I confirm that I will advise the event organiser of any changes to the information provided on this form as soon as
possible
• I authorise designated St John Ambulance volunteers / employees to supervise the administration of any medication as
listed in this form and to administer or arrange first aid treatment as reasonably necessary.
• I consent to attending and completing the activities for this event as outlined in the programme. Any activities that I do
NOT wish the participant to complete have been outlined in Section 4b.

NOTE – If additional events have been detailed in Section 3b then the parent / guardian will need to tick the relevant Consent –
Yes / No choices for each event.

Name: Date:

Signed:

Data Protection

At St John Ambulance we take your privacy very seriously and we are committed to protecting the security of your personal
information. Please be assured that we will never share personal information with third parties to use for their own purposes. For further
information about how we handle your personal information, please refer to our Privacy Policy at www.sja.org.uk/privacy and for information
about how we handle the medical information you provide in this form or during treatment provision, please see our Clinical Privacy Policy.
SJF28 – Joint event consent and medical form for
participants aged 17 or under.

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Any requests for a copy of the Clinical Privacy Policy should be made to the Data Protection Officer: by email- data-protection@sja.org.uk or
by post- marked for the attention of the Data Protection Officer at St John Ambulance, 27 St John's Lane, London EC1M 4BU.

Please return this form, marked private and confidential to the event organiser.