Airplay Consent Form
All information provided will be treated in the strictest confidence. This form MUST be taken on the venture by the Group Leader. A copy should be retained at the home base with a copy of the nominal roll.
Young Person's Details
Name
First Name
Last Name
Date
-
Day
-
Month
Year
Date
Gender
Please Select
Male
Female
Prefer not to say
Group/ Club
Details of Event
Date From
-
Day
-
Month
Year
Date
Date To
-
Day
-
Month
Year
Date
Can they swim unaided?
Yes
No
If Yes, how many meters?
How confident are they whilst wearing a buoyancy aid?
Very confident
Confident only in sheltered waters
Not confident at all
Medical in Confidence
Is the participant receiving medical treatment of any kind? (please state)
Do staff need to supervise the taking prescription medicine? Please state medication and dosage
Do they have (or had previously) any of the following
Asthma/Bronchitis
Heart condition
Fits, fainting or blackouts
Severe headaches
Diabetes
Condition affecting behaviour
Allergies to Penicillin or other known drugs
Disability
Travel Sickness
Haemophillia
Any other allergies
If yes to any of the above, please give details
Do they have any dietary requirements? (Please state)
Medical Centre Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Medical Centre Phone Number
Please enter a valid phone number.
Parent/Guardian Consent
If you do not consent, please leave that section unchecked
Taking Part: I agree to the above named person taking part in this event. Having been informed about the range of activities, I agree to his/her* participation in any or all of the activities described.
Photo & Video Images: I consent to photographic and video images being taken and used to promote RAF Community Support / Airplay activities in line with RAF policy.
Responsible Behaviour: I acknowledge the need for responsible behaviour and understand that I will be responsible for any cost associated with retuning him/her home outside of the stated times.
Medical Treatment: I agree to medical treatment, including anaesthetic, as considered necessary by the medical authorities present.
I understand to inform the Group Leader as soon as possible of any change in the medical circumstances between the date signed and the date of the activity
Print Name
By entering your name this confirms the above consent and that all details given are correct at the time of signing.
Date
-
Month
-
Day
Year
Date
Parent/Guardian Contact Details
Full Name
First Name
Last Name
Home Address
Street Address
Street Address Line 2
City
County
Postcode
Work Address
Street Address
Street Address Line 2
City
County
Postcode
Daytime Phone Number
Please enter a valid phone number.
Evening Phone Number
Please enter a valid phone number.
Mobile Phone Number
Please enter a valid phone number.
Military and Civil Codes
Parent/Guardian Alternative Emergency Contact
If you are not available, who else should we contact
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
County
Postcode
Submit
Should be Empty: