Year 4 E1 Medical Form 2025

Year 4 E1 Medical Form
1 - Child's Name

First NameLast Name
2 - Child's Date of Birth

DayMonthYear
Date
3 - Parent/Carer's Name

First NameLast Name
4 - Place(s) to be visited

Malham YHA, Pennine Way, Malham, Skipton BD23 4DB
Malham Cove

Visit & Deputy Leader

Name of Leader:

Rachel King

Name(s) of deputy:

Sarah Masters

Names of other adults accompanying the party

Abby McAuliffe, Sarah Black, Mehvish Shakil, Nigel Wood, Fatima Bi, Julie Greer, Helen Burrough & Sally Parrini

Name and contact telephone number of school contact person

Sarah Parkinson or Louise Jeynes - 01132930392

Contact for viewing risk assessments.

Rachel King
Declaration
5 - Total number of pupils 90

Age Range

7-11

Total number of staff

12 (4 per class trip)

Name of organising company/agency (if relevant)

Gledhow Primary School & YHA

Transport/travelling arrangements

GSAL coach

Financial Arrangements

Parent Pay payments received £64 for overnight residential experience (£44 for accommodation and meals).
Declaration
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: a walk to Malham Cove and Janet's Foss, learning about rivers and geographical features, evening activity, sleeping over in YHA hostel in Malham and a village treasure hunt the following day before returning to school via coach.

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

N/A
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 4 E1 Medical Form

7 - Medical Needs

14 - Information relating to specific activities.