MAKSATICS LTD. INFORMATION & MEDICAL FORM
THIS FORM IS CONFIDENTIAL
1. Personal Information
Child’s Name as it appears on the passport: …………………………………………………………………………………………………………………………………………………………………………………
Year in present school…………………………………………. Gender ….. FEMALE/MALE
Home Address …………………………………………………………………………………………………
Post code ……………………………………… Country ………………………………………………….
Home telephone Number: ………………………… Mobile Phone……………………………
Date of Birth: ……………………………………..
Alternative Person to Contact in an Emergency ……………………………………………..
Address and Telephone Number …………………………………………………………………………………………………………………………………………………………..
Relationship to your Child …………………………………………………………………..
2. Medical Information
Please detail any Health Problems, Allergies or any other medical conditions/treatments e.g. asthma, Behavioural Problems or Learning Difficulties:
………………………………………………………………………………………………………………
Please list any medication your child will bring on the trip:
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Name address of Child’s Doctor (GP)………………………………………………………………….
Address and Telephone Number of Surgery ……………………………………………………
Please list any allergies:
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Does he/she carry an epipen? YES / NO
Does your child have medical insurance? If so, please list details:
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3. Food Allergies and Essential Food Requirement
Dietary requirements: (vegetarian, dairy intolerant food allergies, Religious beliefs etc)
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4. Is your child a competent swimmer? YES / NO
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Is there any medication your child is not allowed to take e.g. nurofen/calpol? These would only be given if deemed absolutely necessary and every attempt would be made to contact parents.
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I, ___________________________(Name of parent or guardian) agree to my son/daughter ___________ ______________________ (Name) for the teacher/person in charge to treat minor illnesses/injuries, administer first aid and to ensure that any emergency treatment is given in the event of failure to be able to contact me/us.
I agree to my son/daughter taking part in the activities outlined in the group’s prearranged timetable. I understand that my son/daughter will take part at his/her own risk and accept that no responsibility for accidents or injuries or loss or damage to personal property rests with MHADC and the Supervisory Staff, unless proven to be caused by their negligence. I declare that to the best of my knowledge, my son/daughter is competent and medically fit to participate in the activities as part of the group. I agree that medical treatment will be given in the event of an emergency. I understand the information from this form may be stored digitally. I also consent to photographs being taken during the activities to be used SOLELY by MHADC for publicity/training purposes.
Signature ………………………….…
Date…………………………..………
