Flysheet

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Medical form

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Flysheet Camp Medical Form

Dear Parent / Guardian
In order for us to provide the best care possible while you child is with us please fill in the following details. The information on this form will kept confidential and will only be seen by the Children’s Secretary, Camp Organiser and your child’s assigned staff member.

Name …………………………………………………………………………………

Address …………………………………………………………………………………
…………………………………………………………………………………

Date of Birth …………………………………………………………………………………

Attending the camp from …………………… to …..…………………….
1. Is there any specific medical condition of which we should be aware of?
(e.g. asthma, allergies, bedwetting, migraine, fits or any other illness of disability.)
…………………………………………………………………………………………………..
…………………………………………………………………………………………………..

2. Are they receiving any medical treatment at present? Yes No
If yes please give details ……………………………………………………………….
…………………………………………………………………………………………………..

3. Date of last anti-tetanus injection if known.
…………………………………………………………………………………………………..

4. Name and address of family doctor. ………………………………………………
…………………………………………………………………………………………………..

5. Name, address and phone no of emergency contacts (please include relationship to child)
…………………………………………………………………………………………………..
…………………………………………………………………………………………………..

6. Please sign the declaration below:

I will inform Flysheet if …………………………….. comes into contact with any infectious illnesses (German Measles, Measles etc) during the 3 weeks prior to camp. I will hand any medicines to the Flysheet representative. I will ensure there is sufficient medication for the camp.
In the event of illness or accident requiring emergency hospital treatment, I authorise a Flysheet Staff Member to sign on my behalf any written form of consent required by the hospital authorities, if the delay required to obtain my own consent is considered inadvisable by the doctor concerned.

Parent/Guardian ……………………………………………….. Date ………………………………………..

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