Annual Parental Consent Form

To be completed by person with parental responsibility for the child/young person

Childs Full Name* Childs Date of Birth*

Does the above person:

Have a medical condition requiring medical treatment of medication?* Have an allergy to certain medications?* Please give details of medical condition / treatments or allergies to medications below Is s/he able to administer her/his own medications? Has s/he received a tetanus injection in the last 5 years?* I wish to draw the following to the school's/centre's attention (e.g. allergies, special dietary requirements, phobias, travel sickness, toileting difficulties, recent operations or treatments, other conditions which may affect fitness to participate in certain activities:

Emergency Contact Information - Main

Name* Relationship* Address* Telephone Numbers. Day / Evening / Other*

Emergency Contact Information - Other

Name* Relationship* Please enter*