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*

I have read the above information
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*

I have read the above information
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*

I have read the above information
7 - Medical Needs
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.*
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?*

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

CityState / Province

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

CityState / Province

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

CityState / Province

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*

DayMonthYear
Date
Should be Empty:

Year 5 E1 Medical Form

7 - Medical Needs

14 - Information relating to specific activities.