Health Information Form

Medical Information

Part 1 of 2
If it becomes necessary for the Young Person named above to receive medical treatment and I cannot be contacted by telephone or any other means to authorise this, I hereby give my general consent to any necessary medical treatment and authorise the Event Leader or Deputy Event Leader to act on my behalf.
GP Surgery
Surgery Name
GP's Name*

First NameLast Name
GP Surgery's Address

Street Address

Street Address Line 2

CityTown

Postcode
GP Phone Number
Allowed treatments for Headache*
Please list above any treatments which the event leader (or in their absence the deputy event leader) may administer for a headache during the event.
Allowed treatments for Stomach upset*
Please list above any treatments which the event leader (or in their absence the deputy event leader) may administer for a stomach upset during the event.
Allowed treatments for Cold/flu*
Please list above any treatments which the event leader (or in their absence the deputy event leader) may administer for a cold/flu during the event.
Other Allowed treatments*
Please list above any other treatments which the event leader (or in their absence the deputy event leader) may administer during the event. (Eg. Imodium, hay fever tablets etc.)

Medical Information

Part 2 of 2
Any known infection diseases with which they have been in contact in the three weeks previous to the signing of this form*
(E.g. Chicken Pox, Diphtheria, Measles, Mumps, Rubella, Whooping Cough, Covid-19 etc.) Please write the word 'None' if no details needed
Any known allergies / sensitivities / disabilities and details of any known precautions or remedies.*
(E.g. Penicillin, Food Colourings, Face Paint, Travel Sickness, Bed-wetting, Asthma etc.) Please write the word 'None' if no details needed
Details of any known (or under investigation) medical conditions.*
(E.g. Diabetes, Heart Conditions, Kidney failure, ASD, ADHD, Anxiety etc.)
Details of any medicines / treatments currently being taken / followed (including dosage details) and the specialist & hospital concerned if appropriate.*
(Please include any non-prescription preparations, such as cough sweets, herbal medicines etc).(If He / She has to take any medicines, the bottle(s), jar(s) or other items must be clearly labelled with their name and the exact dosages, and the Event Leader MUST be informed on arrival.) Please write the word 'None' if no details needed
Details of any specific dietary requirements:*
(e.g. Vegetarian, Vegan, Lactose intolerance, Gluten free etc) Please write the word 'None' if no details needed

Additional information
Specific Transport arrangements
Eg. Arriving late, leaving early etc. (Please agree above with section leader first)
Additional information you think we may need
Please provide as much detail as possible.

About the Young Person...