POLAND 2018/19 - Consent Form

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Pupil First Name (as appears on passport) *

Pupil Surname (as appears on passport) *

Date of Birth *

YYYY

Year Group *

Gender *

Male

Female

Passport Number: *

Date of Issue: *

YYYY

Place of Issue: *

Date of expiry: *

YYYY

Nationality: *

Does your child suffer from any condition requiring medical treatment, including medication? If YES please give brief details. *

Does your child suffer with any allergies? If YES please give brief details. *

To the best of your knowledge, has your child been in contact with any contagious or infectious diseases or suffered from anything in the last four weeks that may be or may become contagious or infectious? If YES please give brief details *

When was your child’s last tetanus injection? (Please tick where appropriate) *

Within 5 years

Within the last year

Over 5 years ago

Please specify your child's dietary requirements, including if your child is a vegetarian. (All food provided on the trip will be kosher.) *

I undertake to inform the school as soon as possible of any change in the medical circumstances between the date signed and commencement of the journey. *

I Agree

Required

I agree to my child receiving emergency treatment including anaesthetic as considered necessary by the medical authorities present. I authorise the supervisor/teacher to sign on my behalf any written form of consent required. *

I Agree

Required

I agree to my child taking part in the above-mentioned visit and having read the information sheet, agree to his/her participation in the entire programme. I acknowledge the need for compliance with the school rules and responsible behaviour. *

I Agree

Required

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