ST5 parental consent Leisure Centre .pdf

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Cavan and Monaghan Education and Training Board
Form ST5 PARENTAL CONSENT FOR
EDUCATIONAL TOUR/FIELD TRIP
Carrickmacross Youthreach
Details of visit to:
Monaghan Leisure Centre
From: Friday 29th Jan 2016 9:30am
To:Friday 29th January 12:30pm
I agree to ______________________________________
Date of birth __________________ taking part in this
tour/trip and have read the information document.
I agree to participation in the activities described.
I acknowledge the need for the student named above to
behave responsibly and in accordance with the Behaviour
Policy of the school and of Co. Monaghan VEC. I accept
that any student who uses, supplies or is found to be in
possession of drugs, alcohol, solvents, inhalants or other
dangerous substances and/or who engages in behaviour or
actions that are deemed to be a risk to the safety of any
member of the group will result in the offender being sent
home immediately and we the parents will bear the resultant
costs.

Declaration
I/we agree to my/our son/daughter receiving medication as
instructed and any emergency dental, medical or surgical
treatment, including anaesthetic or blood transfusion, as
considered necessary by the medical authorities present. I
understand the extent and limitations of the insurance cover
provided. I further agree that supervisors, under the
direction of the group leader, may administer nonprescriptive medications in accordance with the
manufacturer’s instructions.
Ability To Swim
Give details of your child’s ability to swim
________________________________________
Other Relevant Information:
_______________________________________________
Contact telephone numbers
Work:_____________________________
Home:___________________________________
Home
address:_________________________________________
________________________________________________
Alternative emergency contact:

Medical information about your child

Name:________________________________

a) Any conditions requiring medical treatment, including
travel sickness, and medication required? Y/N

Telephone number:______________________

If YES, please give brief details:
________________________________________________
b) Please outline any special dietary requirements (resulting
from a medical condition) of your child and the type of pain
or cold/flu relief medication your child may be given if
necessary:
________________________________________________
Students may not bring non-prescribed medication with
them. The school will supply this type of medication as per
the information supplied. (Checked with GP)

Address:_________________________________________
___________________________ ____________________
Name of family
doctor:__________________________________________
Telephone
number:__________________________________
Address:_________________________________________
_____________________________________________
Signed: ________________________________ (Parent 1)

c) Does your child suffer from any condition requiring
prescribed medication? Y/N
If Yes please give FULL details of illness and/or
medication:
________________________________________________

________________________________ (Parent 2)
Date: _________________________________

d) To the best of your knowledge, has your son/daughter
been in contact with any contagious or infectious diseases
or suffered from anything in the last four weeks that may be
contagious or infectious? YES/NO

I have read and understand the meaning and implications
regarding all aspects of this form

If YES, please give brief
details:__________________________________________

Signed: ________________________________ (Student)

e) Is your son/daughter allergic to any medication including
non-prescriptive medications? Y/N

Full name (capitals)

If YES, please
specify:_________________________________________
I will inform the Group Leader/Principal as soon as possible
of any changes in the medical or other circumstances of my
son/daughter between now and the commencement of the
journey

Date: _______________________________
_______________________________________________
A COPY OF THIS FORM MUST BE TAKEN BY THE GROUP
LEADER ON THE TOUR/TRIP.
THE ORGINAL SHOULD BE RETAINED BY THE SCHOOL
CONTACT.


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