SAYERS CROFT PARENTAL AGREEMENT FORM -

Sayers Croft Journey-Year 5

Year 5 visit to Sayers Croft, Surrey
Monday 19th September – Friday 23rd September 2022

Full Name of Pupil:

Gender *

Girl

Boy

Date of Birth:

Home Address:

Main Emergency Contact:

My address during the period from 29th June to 1st July will be:

Day Time Telephone:

Evening Telephone:

List below 3 additional emergency contact numbers:

1 . Name & relationship to child *

1.Telephone Number *

2. Name & relationship to child *

2. Telephone Number *

3. Name & relationship to child *

3. Telephone Number *

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’

Does your child have any pre-existing medical conditions? *

Yes

Does your child have any illnesses or undergone any hospital treatments within the past two years ? *

Yes

Dates of illness or duration of stay in hospital (approximate if necessary) *

Nature of condition or type of illness *

Name and address of hospital (if appropriate) with name of doctor *

Date of your child's anti-tetanus injection *

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? *

Yes

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? *

Yes

Please give details of 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, *

Yes

Please list below any medical conditions that your child suffers from

Does your child need any medication during the journey? *

Yes

These include Asthma Inhalers, over the counter medication such as Calpol, Benadryl, Piriton

Please list all medication including the dosage

We need the medication to be given to school by Monday 20th June. Please do not bring in medication on the day of the trip.

Name of Medication

Dosage/time

Add Remove

Has your child been treated for any heart/circulatory/stroke/high blood pressure/breathing/ cancer/diabetic conditions? *

Yes

Let us know if your daughter is due to have her period during school journey week.

6. Does your child suffer from travel sickness and will they need travel sickness tablets? *

Yes

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

GP Name *

GP Telephone *

GP Address *

Please give the pupil’s NHS Number (as shown on the Medical Record Card or obtainable from your doctor’s surgery) *

Dietary Needs

Please Note:

Every effort is made to cater for medical, ethical or religious diets; however, Sayers Croft is unable to cater for individual likes and dislikes
The vegetarian option is only available to those who have chosen the vegetarian or halal option. Those choosing the halal option are offered the vegetarian option unless there is enough demand for us to provide a halal meat option.

If a child has a particularly restrictive diet, it is possible for them to supply their own meals to be heated at Sayers Croft

Dietary Needs

Able to eat anything

No Beef/No Pork

Vegetarian (can eat eggs)

Vegan (Plant based food only)

Halal (Halal Meat and Fish)

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).

Parent/Guardian Name

Parent/Guardian Signature

Clear

Date

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