Permission Slip

Permission Slip
Child's Name

First NameLast Name
Child's Address

Street Address

Street Address Line 2

CityCounty

Post Code
Date of Birth
School Attended
Does your child have a medical condition?
If yes what is the condition?
If your child is on any medication please give details
Is your child allergic to anaesthetics?
Does your child have any allergies (please specify)
Can we apply plasters?
Can we apply suncream? (please refer to our suncream policy)
In the event of an emergency I agree to my child receiving MEDICAL/DENTAL attention. I can be contacted at:
Name
Relationship
Home Phone Number
Work Phone Number
Mobile Phone Number
Alternatively Contact: (Name)
Relationship
Home Phone Number
Work Phone Number
Mobile Phone Number
I give consent to my son/ daughter to take part in all the activities offered in the holiday programme. I understand that the programme can change at short notice and that my child will be travelling by foot, bus, taxi, train or ferry.
Signature
Date

MonthDayYear
Date
Relationship to Child
Should be Empty: