Year 6 E1 Medical Form

Year 6 E1 Medical Form
1 - Child's Name

First NameLast Name
2 - Child's Date of Birth

DayMonthYear
Date
Place(s) to be visited

Whitby YHA
Whitby Abbey
Beach
Coastal walk to Sandsend
Ghost walk around Whitby
Boat Trip RNLI Museum
Whalebone Arches, Whitby

Venue: Whitby YHA, East Cliff, Abbey House, Whitby YO22 4JT

Name and contact telephone number of school contact person

Louise Jeynes or Sanyu Buwule - 01132930392

Contact for viewing risk assessments:

Georgina Green

Visit & Deputy Leader

Name of Leader: Ellie Chainey

Name(s) of deputy: Emilia Sharpe/Atiyyah Bashir

Names of other adults accompanying the party

TBC
3 - Parent/Carer's Name

First NameLast Name
Total number of pupils

TBC - 76

Age Range 10-11

Total number of staff

8

Name of organising company/agency (if relevant)

N/A

Transport/travelling arrangements

Coach (GSAL) from Gledhow to Whitby 13/10 @9am. Return from Whitby to Gledhow 15/10 @12.30pm

Financial Arrangements

Cost of trip: £115.03
Instalment 1: £30.00 04 Dec 2024
Instalment 2: £20.00 31 Jan 2025
Instalment 3: £20.00 28 Feb 2025
Instalment 4: £25.00 28 Mar 2025
Instalment 5: £20.00 25 Apr 2025
Declaration
Declaration
6 - Brief details of programme of activities

Self-guided residential trip to Whitby. Staying in YHA near the Abbey. Map-making skills, historical enquiry, coastal erosion & geographical investigation, team-building activities.

Brief details of adventurous/ hazardous activities and associated specific requirements/qualifications.

Boat trip on sea around Whitby harbour, organised trip with Bark Endeavour
Declaration
7 - Medical Needs
Does your child suffer from any conditions requiring medical treatment?
8 - Please give brief details and describe the medication, (including the name, dosage and frequency required). If the schools policy is to administer medication then by signing this form you are giving your consent for staff to administer any agreed medication.
Declaration
9 - If your child has been diagnosed with asthma please take any prescribed inhalers on the school trip. Please sign below to confirm your agreement that we may use a school salbutamol inhaler if the pupil’s prescribed inhaler is not available, broken, or empty.
10 - Has your son / daughter been in contact with any contagious or infectious diseases or suffered from anything in the last four weeks that may be or may become contagious or infectious?
Please give details
11 - Is your son / daughter allergic to any medication or suffers from any allergies?
Please specify
12 - Has your son / daughter received a tetanus injection within the last five years?
13 - Please outline any special dietary requirements of your child.
14 - Information relating to specific activities.
For adventurous / hazardous activities detailed in item 6, does your child suffer from any medical condition that may affect their ability to undertake the activities?
15 - Does your child have any specific needs or conditions that affect overnight stays e.g sleepwalking, bed wetting, frequent nightmares, trouble sleeping.
Please give brief details
16 - Declaration
17 - Emergency Contact 1 Name

First NameLast Name
18 - Emergency Contact 1 Relationship to Child
19 - Emergency Contact 1 Address

Street Address

Street Address Line 2

CityState / Province

Post Code

20 - Emergency Contact 1 Phone (add 1 minimum)

Rows	Number
Mobile
Home
Work

21 - Emergency Contact 2 Name

First NameLast Name
22 - Emergency Contact 2 Relationship to Child
23 - Emergency Contact 2 Address

Street Address

Street Address Line 2

CityState / Province

Post Code

24 - Emergency Contact 2 Phone (add 1 minimum)

Rows	Number
Mobile
Home
Work

25 - Doctor's Name
26 - Doctor's Address

Street Address

Street Address Line 2

CityState / Province

Post Code
27 - Doctor's telephone number
Please enter a valid phone number.Format: 00000 000000.
28 - Child's NHS number
29 - Declaration
30 - I have provided all required information above including medical information, emergency contacts, doctor's information and NHS number.
31 - Form completed electronically by

First NameLast Name
Date

DayMonthYear
Date
Should be Empty:

Year 6 E1 Medical Form

7 - Medical Needs

14 - Information relating to specific activities.