Educational Visit Consent & Medical Form

To be completed and signed by students over 18 years of age or by a parent

or guardian for students under 18 years of age and SLDD students under 25
years of age
Visit to:
Greenwich Picturehouse, 180 Greenwich High Road, Lonodn SE10 8NN
Students name:

Student Number:

Are there any activities in which you/your son/daughter/ward should not

participate. If so, please give details:

Name, address and contact details of students doctor:

Are you/is he/she allergic to anything, e.g. medicines, food, pollen, etc? If
so, please give details:

Do you/does he/she suffer from any of the following? Asthma, chest

complaints, migraine, bad period pains, travel sickness, diabetes, fits or
faints? If so, please give details:

Are you/is he/she having any medical treatment at present? If so, please
give details of treatments and medicines: (Please remember that prescribed
medicines may be handed in, before departure, to the staff in charge in their original,
labelled box / bottle for safe keeping.)

Do you/does your son/daughter/ward have any physical disability? Please

give details of any special attention required:

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Please use this space to inform the staff in charge, in confidence, of any
other medical condition or health problem that may affect you/your
son/daughter/ward during this visit: (If you would prefer to communicate
confidential information in writing to the party leader, please do so.)

Date of last anti-tetanus injection:

Please indicate any special food / dietary requirements:

In the event of me/my son/daughter/ward not conforming to the standards of

behaviour required by the member of staff in charge of the visit, I will personally be
responsible for all arrangements to get myself/my son/daughter/ward home.

I, _________________________________________
(YOUR NAME IN BLOCK CAPITALS PLEASE)
give consent to my medical examination/the medical examination of my son/daughter/ward when
necessary whilst I am/he/she is taking part in the visit and I request that any operation or any other
measures considered necessary, by a medical authority, for my/his/her diagnosis and treatment shall
be performed and I hereby give permission for such an operation or other measures to be carried out in
an emergency only and for the administration of general or local anaesthetic if necessary.
I am willing / not willing to take part/for my son/daughter/ward to take part in the visit detailed and,
having read all the information provided, agree to taking part/him/her taking part in any of the activities
mentioned except those specified.

Signed:

_______________________________

Date:

_______________________________

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