Medical and Consent Form (PDF)

Medical and Consent Form
Name of Young Person (YP)
YP contact number
1st Parent/Guardian (PG) Contact Name
PG contact number
2nd PG Contact Name
2nd PG contact number
3rd PG Contact Name
3rd PG contact Number
What is the name of the YP GP?
Address of GP

GP Telephone Number
Is the YP fluent in English?
Does the YP have any known health
conditions?

Does the YP take any medication?

Does the YP have any allergies?

Has the YP been in hospital for any
reason in the last 2 years? If yes, please
state.
Does the YP have any of the following
(If you tick any box, please state in the
space below tick boxes)

Learning Difficulties
□
Mobility Requirements □
Visual Impairment
□

Physical Disabilities □
Hearing Impairment □

Is the YP able to swim unaided?
Does the YP have any overnight care or
support?
Do we have consent to take photos of
the YP whilst on programme? These
photos may be used on social media or
for promotional purposes.

Yes
Yes

No
No

Yes

No

Is there any other reasons you feel a YP may not be able to partake in any physical activity?

Is there any other information which you feel the staff on programme may need to know about
the YP. Please include anything here, no matter how insignificant you may feel it is.

By signing below, I confirm that all of the above information is true and correct. If at any point this
information changes, I will let Southend United Community and Educational Trust know.
Name (print):

Relationship to YP:

Signed:

Date: