Professional Documents
Culture Documents
Name of Centre ...FERNDOWN OPEN AWARD CENTRE…………………...........................................
Name of Participant...............................................................……..............…......................................
Address of Participant .....................................................................……..........…................................
.................................................................................……..….................................……………………..
Postcode ................................................................
Telephone No ................................................................
Date of Birth ..................................……………….........
DH/NHS No ..................................……………….........
Passport No.(foreign travel) .....N/A....................................………………..
Form E111 held for EEC travel? YES/NO N/A
Doctor's Name……..........................................................................………………………………...……...
Doctor's Address
..................................................................................………………………………..…..
Postcode ..............................................................…
Doctor's Telephone No ..............................................................…
Doctor's Emergency Contact ..............................................................…
Next of kin: Name................................................................………………………………....……………..
Address
..........................................................................………………………………..........…………….
..........................................................................………………………………..........……………………….
...........................................................................……………………………….........……………………….
Postcode ..............................................................…
Telephone No: Home .................................................................
Work .................................................................
Tetanus
Has the participant an uptodate tetanus injection? YES/NO
Special Details:
Any relevant information concerning the participant's health requiring special attention, but which does not
prevent him or her taking part. Delete as applicable, all YES answers must give details below:
Does the participant suffer from allergies? YES/NO
Take medication, if so what is the dosage required? YES/NO
Experience travel sickness? YES/NO
Has diabetes, asthma or epilepsy? YES/NO
Has the participant had any relevant recent illness? YES/NO
(NB staff are not permitted to administer medication)
DIET:
Does the participant require vegetarian/vegan meals? YES/NO
Does the participant have any specific medical dietary requirements? YES/NO
Is there anything else we should know? Detail below YES/NO
continued…
DETAILED INFORMATION:
SWIMMING ABILITY FOR WATER ACTIVITIES
Is the participant/are you able to swim 50 metres YES/NO
Is the participant/ are you confident in the water YES/NO
STATEMENT
I ACKNOWLEDGE RECEIPT OF AND UNDERSTAND THE INFORMATION REGARDING THE
PROPOSED DUKE OF EDINBURGH’S AWARD SILVER PRACTICE EXPEDITION IN THE
PURBECKS BETWEEN FRIDAY 25 – SUNDAY 27 APRIL 2008 AND CONSENT
TO..................………………………….................................................PARTICIPATING
I have ensured that the participant understands the information for his/her safety and for
the safety of the group that any rules and instructions given by staff are obeyed.
I agree to the participant/self receiving emergency medical treatment if necessary. I understand
that the party leaders will do their best to contact me prior to such treatment.
I consent to the participant/self travelling by any form of public transport and/or in any approved
motor vehicle driven by a suitably qualified and approved member of the party.
I understand that arrangements for the care, supervision and discipline will be in accordance
with the normal policies and practice of the Youth Centre. I agree to reinforce the need for the
participant to/ follow the Youth Centre's code of behaviour.
I confirm that the participant is in good health and I consider him/her fit to participate and agree
to inform the staff if there are any changes to the above information.
I understand that whilst every reasonable care will be taken, the Centre and its staff cannot be
held responsible for damage to or loss of property whilst taking part in this activity.
I give permission to allow photographs taken during the course of these
Yes No activities to be used in promotional presentations and materials .
Please tick the box
My attention has been drawn to the desirability of arranging insurance in respect of
personal accident cover.
SIGNED ...........................…………………............................ Parent/Person with Parental responsibility
(if participant under 18)
or ........................................................................................... Participant if over 18
Date ………………………………………………….
I understand that for the group's and my own safety, I will undertake to obey the rules and
instructions of members of staff
Signature of Participant ...........................................………………………….…….....
Date ............…..............……………..........