Doctor's name and address
Doctor's Telephone ________________________
Date of last anti-tetanus injection (if known)
Has he/she been in contact with any infectious disease within the past three
months? Yes No
Is he/she taking any medicine that needs to be continued during the visit?
Does he/she suffer from any allergies, recurrent illness, bad period pains
or other illness or disability? Yes No
Other relevant medical
I have been notified of the travel arrangements and the rules for the visit.
I have seen the programme of events.
I have been notified of the name and address of our child's hosts.
I agree to reimburse the organisers for any out-of-pocket expenses incurred
in dealing with difficulties or incidents for which my child is responsible,
including accompanying my child back home following serious misconduct.
I hereby give consent for the child named above to
take part in the activities of the event named above. In the event of a
medical emergency I authorise the Leader named above to sign any consent form
considered necessary by hospital authorities,
if the delay required to obtain my own consent is considered inadvisable by the
doctor or surgeon concerned.
______________________________________________Parent / Guardian
Name ______________________________ Date