MEDICAL CONSENT FORM

Name

Email Address

Phone Number

Date of activity

Description of activity

Date of birth

First line address

Postcode

Are you allergic to anything? (eg antibiotics, plasters, aspirin or any medicines, any particular food etc) Are you allergic to anything? (eg antibiotics, plasters, aspirin or any medicines, any particular food etc) Yes No

Please give details

Are you actively sensitive to penicillin? Are you actively sensitive to penicillin? Yes No

Please give details

Are you receiving any medical treatment at present that we need to know about? Asthma and hay-fever treatment are your responsibility and do not need to be included here Are you receiving any medical treatment at present that we need to know about? Asthma and hay-fever treatment are your responsibility and do not need to be included here Yes No

Please give details

Do you have any special dietary needs? Do you have any special dietary needs? Yes No

Please give details

Name

Phone Number

First line address

Postcode

Consent Consent I consent to any emergency treatment necessary, If in the opinion of the doctor concerned the delay required to obtain the signature of my next of kin might be considered likely to endanger my health or safety, I authorise the party leader(s) to sign, on my behalf, any written form of consent required by the hospital authorities should medical treatment be deemed necessary.

I give permission for photographs to be used for Mountain and Moors Adventures marketing purposes. I give permission for photographs to be used for Mountain and Moors Adventures marketing purposes. Yes No

Name

Relationship to self

Emergency contact number

Name

Relationship to self

Emergency contact number