Year 5 E1 Medical Form 2025

Year 5 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
Place(s) to be visited

Ingleborough
Hawes YHA
Yorkshire Dales Museum

Group Leaders and Supervising staff
Laura Johnstone
Michael Walker
Sam Birkby
Fatima Bi

Name and contact telephone number of school contact person

Rachel King or Sanyu Buwule - 01132930392

Contact for viewing risk assessments.
Laura Johnstone

Visit & Deputy Leader

Name of Leader:

Laura Johnstone - Mulberry Class

Name(s) of deputy:

Michael Walker

Names of other adults accompanying the party

TBC
Declaration
Total number of pupils 81

Age Range

7-11

Total number of staff

TBC

Transport/travelling arrangements

GSAL coaches
Bibbys coaches

Financial Arrangements
Parent Pay payments received £167.50 per person
Declaration
6 - Brief details of programme of activities

We will be doing a range of activities to build perservence, ambition and understanding of the local are of Yorkshire. These will include: climbing Ingleborough, visiting different sites / activities in the town of Hawes, such as the Dales Museum. The majority of these activities will be led by your child’s group leader or member of staff from Alfresco Adventures outdoors company.

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

Adventure Walk and abseil with Alfresco Adventures outdoors company
Fell climbing for Ingleborough
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 5 E1 Medical Form

7 - Medical Needs

14 - Information relating to specific activities.