Year 3 E1 Medical Form 2025

1 - Child's Name*

First NameLast Name

2 - Child's Date of Birth*

Date

3 - Parent/Carer's Name*

First NameLast Name

4 - Place(s) to be visited

Gledhow Primary School, Leeds, LS8 1PL

Venue: School Field and Annexe Building

Visit & Deputy Leader

Name of Leader:

Sam Birkby

Name(s) of deputy:

Sarah Parkinson

Names of other adults accompanying the party

Atiyyah Bashir, Michael Walker, Lara Byrne, Paula Walton, Rachel King, Maryam Umar, Laura Johnstone

Name and contact telephone number of school contact person

Sarah Parkinson or Louise Jeynes - 01132930392

Contact for viewing risk assessments.

Sam Birkby

Declaration*

I have read the above information

5 - Total number of pupils 82

Age Range

7-11

Total number of staff

11

Name of organising company/agency (if relevant)

1. The Outdoors People CIC

Transport/travelling arrangements

N/A

Financial Arrangements

Parent Pay payments received £57 for overnight experience or £49 contribution for next day activities

Declaration*

I have read the above information

6 - Brief details of programme of activities

We will be doing a range of activities to build resilience, team working skills, communication and personal development. These will include: Life Skills, Crash and Carry, Bug-Buns and Blazes and Water Purification. The majority of these activities will be led by the Outdoor People instructors or your child’s group leader.

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

N/A

Declaration*

I have read the above information

Does your child suffer from any conditions requiring medical treatment?*

YesNo

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*

I have included information stating the name, dosage and frequency.(e.g. Kalm's travel sickness, one tablet, 20 minutes before journeys over 2 hours)

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.*

I agree to the school using a salbutamol inhaler.Not Applicable

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?*

YesNo

Please give details*

11 - Is your son / daughter allergic to any medication or suffers from any allergies?*

YesNo

Please specify*

12 - Has your son / daughter received a tetanus injection within the last five years?*

YesNo

13 - Please outline any special dietary requirements of your child.*

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?*

YesNo

15 - Does your child have any specific needs or conditions that affect overnight stays e.g sleepwalking, bed wetting, frequent nightmares, trouble sleeping.*

YesNo

Please give brief details*

16 - Declaration*

The School or its agents will not be held liable for any injury or death arising directly or indirectly from or out of the administration of the prescribed medication by appointed staff members, other than through the School’s negligence.I understand that the decision to provide emergency medical treatment rests with the medical authority. I will provide information below to assist a medical practitioner in their decision to give emergency treatment.The school can share my information with emergency services and other specialist parties if required and as needed for the purposes of health, safety and wellbeing.

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

City

Post Code

20 - Emergency Contact 1 Phone (add 1 minimum)*

	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

City

Post Code

24 - Emergency Contact 2 Phone (add 1 minimum)*

	Number
Mobile
Home
Work

25 - Doctor's Name*

26 - Doctor's Address*

Street Address

Street Address Line 2

City

Post Code

27 - Doctor's telephone number*

Please enter a valid phone number.

28 - Child's NHS number*

29 - Declaration*

I agree to my son / daughter taking part in the visit outlined above and, having read the information sheet, agree to his/her participation in any or all of the activities described. I acknowledge the need for obedience and responsible behaviour on his/her part.I undertake to inform the Visit Leader as soon as possible of any change in the medical circumstances outlined above between the date signed and the commencement of the visit.

30 - I have provided all required information above including medical information, emergency contacts, doctor's information and NHS number.*

Yes

31 - Form completed electronically by*

First NameLast Name

Date*

Date

Year 3 E1 Medical Form

7 - Medical Needs

14 - Information relating to specific activities.