SAYERS CROFT PARENTAL AGREEMENT FORM

Sayers Croft Journey

Sayers Croft Journey

Year 5 visit to Sayers Croft, Surrey
Wednesday 22nd – Friday 24th September 2021

Gender *

Main Emergency Contact:

List below 3 additional emergency contact numbers:

Details of illness or hospital treatment

Please insert below any details of any illness or hospital treatment suffered or undergone by the pupil within the past two years or any pre-existing medical condition. If there are none, please mark ‘NONE’

Infectious diseases

Has the pupil been in contact with anyone suffering from an infectious disease during the past three weeks and has there been any infectious disease in the house during that time?

Known allergies

Please give below a list of substances including drugs, foodstuffs and other substances to which the pupil has suffered an allergic reaction at any time. If the pupil suffers from hayfever please state ‘Hayfever’ below.
Does your child suffer from any allergies?

Medical Conditions and Medication

If the pupil requires any medication during the journey, it is the responsibility of the parent to provide drugs in a suitable container, which is clearly labelled with the child’s name, the name of the drug and dosage to be given. An adequate supply must be provided to cover the whole of the trip if necessary.
Does your child have any other medical conditions ? ie. Asthma,
Does your child need any medication during the journey?

Please list all medication including the dosage

Has your child been treated for any heart/circulatory/stroke/high blood pressure/breathing/ cancer/diabetic conditions?
6. Does your child suffer from travel sickness and will they need travel sickness tablets?

Please give the name, address and telephone number of the pupil’s General Practitioner:

I, the parent/guardian of the pupil named above:

  • 1. Hereby give permission for the pupil to attend the visit detailed, between the dates shown above, or between such other dates (including an extension of time) as may be substituted therefore;
  • 2. Note that the Council and the teacher named above are not liable for any claim or claims of whatsoever nature arising during the visit referred to above by virtue of the attendance of the pupil except incidents arising from the negligence of the Council or its servants;
  • 3. Warrant that the information give (overleaf) is correct to the best of my knowledge;
  • 4. Agree that the said teacher named above (or any other teacher who may from time to time be in charge of the visit) may act on my behalf in all matters affecting or concerning the pupil. I understand that all reasonable efforts will be made to contact me before taking any action, but in particular cases this may not be possible.
  • 5. Agree to the Council making any further enquiries that it considers necessary to establish whether the pupil is medically fit to participate in the visit refereed to above in the light of any information given overleaf. In the even of the Council deciding, in its absolute discretion, that the pupil is not medically fit to participate, I understand that any sum paid by me in respect of any costs or expenses of the journey will be refunded to me in full (less a deduction covering administrative expenses and deposit).
Dietary Needs *
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