MEDICAL LIST

Activity Registration form

PLEASE PROVIDE AN UP TO DATE, ACCURATE AND COMPLETE LIST OF ALL THE PARTICIPANTS DETAILS, MEDICATIONS, DISABILITIES & DIETARY REQUIREMENTS. THE MEDICATION WILL NEED TO COME TO THE ACTIVITY AND IN LABELLED PACKAGES - STATING THE NAME AND DOSE.
*I understand that SAFE Equestrian relies on the medication, allergy and disability information I provide for the care of the participant, be that myself or my child, and that any misinformation can result in hospitalisation or death. By typing my name below, I acknowledge that the information I am providing is accurate and complete.
*Type your Name here*

First NameMiddle NameLast NameMiss/Mrs/Mr/Master
The Childs Name*

First NameMiddle NameLast NameMiss/Master
Child's Gender*
Child's Birth Date*

DayMonthYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Child's School*
Fuelled Code*
Child's Parent/Carers E-Mail*

Confirmation EmailConfirm E-mail
Childs's Parent/Carer Phone Number*

Area Code (+44)Phone Number
Please State if you consent to your child being included in SAFE equestrians phots, social media posts and photos shared with the activity fundings providers*

YesYes, unnamed and with face coveredNo
CHILD'S Medical information
Does the child SEN?*

YesNoUnknown
Does the child have any disabilities?*

YesNoUnknown
If Yes, please explain below
Does the child have any Food Allergies?*

YesNoUnknown
If Yes, please list all Allergies plus Reactions:

Name of Medication / Allergic Reaction0/300
Does the child take any regular Medication? (PLEASE SEND THIS WITH THE CHILD, FULLY LABELLED)*

YesNoUnknown
If Yes, please list all Drug/Medication:

Name of Medication, How often and How its taken0/300
Does the child have a dietary requirement*
If Yes, Please give FULL details of their dietary requirements
CHILDS Medications

Be sure to include all medications, diabetic, dietary supplements and vitamins. PLEASE NOTE: ONLY MEDICATION LABELED WITH CHILD NAME, DOES AND ROUTE WILL BE GIVEN, AND WILL BE ADMINISTERED AS STATED.

Please List All Medications

	Medication Name	Dosage Amount	Start Date	Time taken (dose one)	Time taken (dose two)	Time taken (dose three)	Time taken (dose four)	Time taken (dose five)	Time taken (dose six)	addition information
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20

Today's Date*

DayMonthYear
I confirm the following:*

The details I have provided are correct and upto dateI give my permission for the staff at SAFE Equestrian to administer medication as detailed aboveI will provide all medication and application upon arrivalI understand only prescribed, labelled and in date medication can be administered throughout the Participants stayI understand there is a minimum stay over capicity, and if less than 10 campers book to stay over night, over night will not go ahead.

Days wishing to attend *

	SELECT THE DAYS
PONY FANCY DRESS PAMPER & PARADE - SUN 22ND DEC - 10 - 4
CHRISTMAS EVE EVE PARTY : MON 23rd Dec - 10am - 4pm
TWLIGHT OBSTACLE COURSE : THURS 2ND JAN - 2PM - 6PM (must be over 10)
OWN A PONY DAY - FRI - 3RD JAN - 10AM - 4PM

Signature*

Clear
Should be Empty:

Activity Registration form

CHILD'S Medical information

CHILDS Medications