Guildford Grove Primary School and Nursery

Southway, Guildford, Surrey GU2 8YD

Tel: 01483 504713
Fax: 01483 306907
Email: info@guildfordgrove.surrey.sch.uk
Website: www.guildfordgrove.surrey.sch.uk

Headteacher - Rona Mackie

Medical consent form for Year 5 Residential trip to Sayers Croft

I have ensured that my child _______________________________ in class __________ fully understands that it is
important for his/her safety and that of the group that any rules and instructions given by staff in
charge are obeyed.

Please complete ALL of the following sections of this form.

My child has
no illness, allergy or physical disability
My child has the following
illness __________________________________________________________________________________________________
______________________________________________________________________________________________________________

allergy__________________________________________________________________________________________________
______________________________________________________________________________________________________________

physical disability_____________________________________________________________________________________
______________________________________________________________________________________________________________

I consent to any emergency medical treatment as necessary during the course of the visit.
I give consent for my child to be given a mild painkiller (paracetamol) of considered necessary by
the party leader.

I give consent for my child to have a plaster applied as necessary

My child has special dietary requirements

_______________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________

If there is any other information that you feel is important for you childs teacher to know, please
complete the section below

_______________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________

Signed ________________________________________________________________ Date ________________________

(parent/carer/guardian)
 Guildford Grove Primary School and Nursery
Southway, Guildford, Surrey GU2 8YD
Tel: 01483 504713
Fax: 01483 306907
Email: info@guildfordgrove.surrey.sch.uk
Website: www.guildfordgrove.surrey.sch.uk

Headteacher - Rona Mackie

Pupils name _______________________________________________________________________________________________

Date of birth _______________________________________________________________________________________________

Parents name _____________________________________________________________________________________________

Home address _____________________________________________________________________________________________

______________________________________________________________________________________________________________

______________________________________________________________________________________________________________

Home telephone number _________________________________________________________________________________

Mobile telephone number ________________________________________________________________________________

Other contact telephone number ________________________________________________________________________

Doctors name _____________________________________________________________________________________________

Doctors address___________________________________________________________________________________________

______________________________________________________________________________________________________________

______________________________________________________________________________________________________________

Doctors phone number ___________________________________________________________________________________

Has your child had any of the following (please circle ALL questions as appropriate)

Asthma or bronchitis YES NO

Heart condition YES NO
Fits, fainting or blackouts YES NO
Servere headaches YES NO
Diabetes YES NO
Allergies to any known drugs or medication YES NO
Any other allergies YES NO
Other illness or disability YES NO
Any recent contact with contagious diseases or infections YES NO

If the answer to any of these is yes, please give details below

_______________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________