Parent Consent and Medical Forms

Home-School Tutoring Hertfordshire & Cambridgeshire
Parent Consent and Medical Form for Off-Site Visits or Where Parents/Carers are not present

This is for all tuition that takes place away from the tutees home, including school sites (unless the pupil’s own school), or where tuition takes place in the client's home and the parents/carers are not present.

Risk assessments and a new version of this form should be completed for each new venue.

CONFIDENTIAL

(A copy of this information is to be carried by the tutor to every session)
INFORMATION FOR PARENTS / GUARDIANS / CARERS

Please complete the questions below as fully as possible and sign the consent.

The personal and medical information requested is vital to ensure that appropriate care and support is available for each child/young person. Please consult your family doctor if you are unsure about the safety of tuition occurring in specific venues or a specific visit.

Medical conditions will not necessarily exclude any child from participating in tuition outside of the home or specific activities, but tutors should be made aware of anything that might affect the safety/welfare of this young person.
Contact Details
Name of Child:*

First NameLast Name
Date of birth: *

DayMonthYear
Date
Address*

Street Address

Street Address Line 2

Town/CityCounty

Post Code
Parent/Carer Name:*

First NameLast Name
Second Parent/Carer Name (if applicable):

First NameLast Name
Address (if different from child's address):

Street Address

Street Address Line 2

Town/CityCounty

Post Code
Parent/carer 1) Daytime Phone Number*

Area CodePhone Number
Parent/carer 1) Evening Phone Number*

Area CodePhone Number
Parent/carer 1) Mobile Phone Number*

Area CodePhone Number
Parent/carer 2) Daytime Phone Number

Area CodePhone Number
Parent/carer 2) Evening Phone Number

Area CodePhone Number
Parent/carer 2) Mobile Phone Number

Area CodePhone Number
Additional Emergency Contact Name:*

First NameLast Name
Additional Emergency Contact Relationship to child:*
Additional Emergency Contact Number:*

Area CodePhone Number
GP Name and Phone Number:*
Consultant or Hospital Contact Details (if applicable):
Please include a contact name, hospital name and contact number
Please list any medication your child takes including the dose and times:
Medical or Special Needs

Please provide all relevant information which will enable the tutor(s) to safely care for this young person. If any sections aren't applicable, please use N/A.
Describe any medical needs of this young person and give details of child’s symptoms, triggers, signs, treatments, equipment/devices or environmental issues etc:*
Medical Diagnosis or condition? (Please also include any impairments or disabilities we should be aware of):*
YesNo
If yes, please provide details:
YesNo
If yes, please provide details:
YesNo
If yes, please provide details:
Please provide details of specific support for the pupil’s educational, social and emotional needs:*
Describe what constitutes an emergency, and the action to be taken if this occurs?*
In the event of a fire emergency is this young person able to use stairs with support from a member of staff?*
Is the venue suitable for this young person? Any points to note?*
Please inform Home-School Tutoring if this child comes into contact with any infectious illness or if their medical condition changes or new needs arise.
Minor Medical Treatment

Young people sometimes need minor medical treatment for conditions such as insect bites or paper cuts etc. If necessary, with your permission, in exceptional circumstances tutors may seek treatment for these ailments with the following “off the shelf” products which are commonly available in first aid kits that may be in a first aid kit on site: antiseptic cream, calamine lotion, antiseptic wipes, hypoallergenic adhesive plasters, witch hazel, insect bite antihistamine.
YesNo
Please note: We never facilitate pupils being given paracetamol or other pain relief.

In the case of a child needing such treatment we would get in touch with the parent/carer either to come and collect the pupil or for them to bring and administer pain relief to their child.
Emergency Medical Treatment

The default would be to call the parent/carer in the event of any emergency as soon as possible.However, in exceptional circumstances this may not be possible.
YesNo
Parent/Carer Signature to confirm consent for Emergency Medical Treament:*
PARENT/ CARER/ GUARDIAN DECLARATIONS and CONSENT
I am legally responsible for the care of the child mentioned above.I have listed all relevant medical or other conditions concerning this child that might affect the dutyof care expected during education taking place outside of the home.I undertake to inform the Tutor and whoever has commissioned the tuition (in writing) of any changesin the medical or other circumstances of this child.I consent to my child to taking part in tuition.
Parent/Carer Signature: *
Parent/Carer name:*

First NameLast Name
Date: *

DayMonthYear
Date

Client Request to Leave a Minor with the Tutor

Home-School Tutoring makes every effort to ensure that the tutors they recommend are qualified, experienced, referee and DBS checked. The responsibility for the pupil, however, remains with the parent/carer/school where tuition is taking place and the responsible adult should remain on the premises.

We do, however, understand that there are circumstances where the responsible adult may ask to leave the tutor with the pupil for a time, if all parties are comfortable with this arrangement.

Our preference for this scenario would be for tuition to take place in a public place such as a library or café where possible.

Please complete this section if a tutor is to be alone with the student.
Parent/Carer name:

First NameLast Name
Second Parent/Carer name (if applicable):

First NameLast Name
Name of minor:

First NameLast Name
Tutor name:

First NameLast Name
By signing below the parent(s)/carer(s) named above agree to the following:

Tutor First Name Tutor Last Name is contracted by me/us as a tutor for Student First Name Student Last Name for whom I have responsibility.

I/we acknowledge that I/we retain responsibility for Student First Name StudentLast Name during his/her tuition session and I/we will provide the tutor with emergency contact details and any medication information by completing the Parent Consent and Medical Form for Off-Site Visits or where Parents/Carers are not present.

The safeguarding of children is of prime importance to us all and we understand that the tutor(s) reserve the right to cancel/discontinue the session if they are in any way uncomfortable, or feel that it would be inappropriate for any reason to continue.
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Parent/Carer name:

First NameLast Name
Parent/Carer Signature:
Date

DayMonthYear
Date
Should be Empty:

Home-School Tutoring Hertfordshire & Cambridgeshire

Contact Details

Medical or Special Needs

Minor Medical Treatment

Emergency Medical Treatment

PARENT/ CARER/ GUARDIAN DECLARATIONS and CONSENT