PARENTAL CONSENT FORM

Consent for participation in the Cycling4Life Project

From:……………………To:……………………………..

I agree to my son/daughter……………………………(name) taking part in the above mentioned project and their participation in any or all of the activities described. I acknowledge the need for obedience and responsible behaviour on his/her part and that unreasonable behaviour may lead to him/her being expelled from the programme. I understand that there is some level of risk in every activity but that this visit will be managed to minimise the risks involved. I understand that as part of the planned programme activities students may from time to time have the opportunity to visit external sites under the supervision of Cycling4life instructors. I understand that as part of the planned transport arrangements, or in an emergency, it may be necessary for pupils to be transported in staff vehicles. I acknowledge that I am responsible for my child should he/she leave the site. I agree that my child may participate in any filming/photography activities and that his/her image may be used by the project in connection with any educational/promotional products as a result of any such activity.

Medical information, declarations and consent

Son/daughter’s date of birth:………………………..

Does you son/daughter suffer from any conditions:   Yes/No

If Yes, please give details of anything the project leader needs to know about to safely care for your child e.g. illness, allergies etc.

Details of any medication

Any special precautions, side effects of medication etc:

I give my consent** for a member of staff to administer the above medication which I will deliver to the project leader. I understand the staff delivering the project are not qualified medical practitioners but that they will take reasonable care in the administration of the medication and will endeavour to respond appropriately should emergency treatment be required.

I give my consent** for my son/daughter to self administer the above drugs.

**delete if not applicable

To the best of your knowledge, 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 become, contagious or infectious?:     Yes/No

Is your son/daughter allergic to any medication?:              Yes/No

If Yes, please specifiy:

When did your son/daughter last receive a tetanus injection?

Please outline any special dietary requirements of your child:

I undertake to inform the group leader as soon as possible of any change in the medical or other circumstances between now and the commencement of the journey.

I agree to my son/daughter receiving emergency medical treatment, including anaesthetic and blood transfusion, as considered necessary by the medical authorities present.

Contact numbers

I may be contacted by the telephoning the following numbers:

Work:………………………..Home:………………….Mobile:…………………..

My home address is:………………………………………………………………

……………………………………………………………………………………….

……………………………………………………………………………………….

If I am not available, please contact:

Name:………………………………..Telephone Numbers:…………………….

Address:…………………………………………………………………………….

……………………………………………………………………………………….

……………………………………………………………………………………….

Name, address and telephone number of family doctor:………………………

……………………………………………………………………………………….

……………………………………………………………………………………….

Any other relevant information

Signature…………………………………………..

Date:…………………………………………………

Full Name (capitals)………………………………..