Health and Permission Form

Activity Details

This just allows us to direct your form to the correct Leader and activity.

Name of the activity/camp (and year) *

Who is the activity Leader in Charge? *So we can send the health form to the correct leader.

Participant Details

These details relate to the participant (Explorer or Adult Leader) taking part in the activity or trip

Participant Name *

Participant Mobile Number *

Participant Date of Birth *

Day

Month

Year

1st Line of Home Address *

Post Code

GP Surgery Details

Let us know the GP Surgery details of the participant. This can be vital in quickly finding previous health records if a medical professional needs them.

GP Surgery Name *Ie the name of your GP Surgery, not the GP themselves.

GP Post Code *

Additional Details

Please tick all that apply to the participant

Please select all that apply to the participantMedication to be taken/could be needed (includes Asthma)Has dietary requirementsHas a disability or additional needsHas allergiesHas been ill, or in contact with an infectious disease in the last 12 weeks

I confirm the participants doesn't have any additional needs that should be brought the the Leader's attention, and if they change before the activity, a new form must be completed. *Yes

Medication Details *Please include full details of all medication that the participant will need, or could need. Please include brand names, dosage requirements, timings and any other relevant information you think will be required.

Is the participant able to keep the medication on them, and self-medicate without prompt, or does a leader need to take charge of medication *

Sign to confirm that the participant is able to look after, self-medicate, and does not require any intervention from an adult re any of their medication *

What dietary requirements do they have? *VegetarianVeganOther

Tell us more about their dietary requirements *

Tell us more about their disability / additional needs *

Tell us more about their allergies *

Tell us more about the illness/disease they've been in contact with in the last 12 weeks *

Emergency Contacts

If we need to contact you, please let us know who to contact in what order

Emergency Contacts

Emergency Contact Name *

Relationship to participant *

Emergency Contact 1 Mobile Number *

Emergency Contact 1 Additional Number

1st Line of Address *

City *

Post Code *

Consents and Agreements

Please ensure you carefully read and agree to the below agreements and consents. You will be required to sign for these on the next page.

Can the participant swim at least 50 meters and stay afloat for 5 minutes, in clothing? *

Do you (and the participant) agree for photos and videos to be taken during the event, and uploaded to our social media platforms and/or website, both during and after the event? *

Sign and Submit

Please sign and submit your form below.

Signature *

Your Name *

Your Email Address *So you can get a copy of this form

Your relationship to the participant *

Today's Date *

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Activity Details

This just allows us to direct your form to the correct Leader and activity.