Name

First

Last

Address

Address 1

Address 2

City

State

Postal Code

Country

Phone Number

Date of Birth

Email

EMERGENCY CONTACT (Name, Relationship to You, Telephone/Mobile Number)*

Any Dietary Allergies?

Medical Information*Please tick if you have any of the following:

Rheumatic Fever Asthma

Fainting Spells

Diabetes

Kidney Disease

Heart Trouble

Hernias

Travel Sickness

Epilepsy

Other (Indicate in box below)

None of the Above

Any other Medical Illnesses not indicated above.

Have you been given any specific advice to follow in emergencies?

Are you taking any medication we should be aware of? If yes, please give name of drug and dosage details:

Please give details of any current/past illnesses or medical conditions of which we should be aware of.

Health Information (Please enter name of GP, Address and Telephone Number)*

Current regulations relating to Child Protection issues and taking photographs of young people require that we obtain your consent for any picture taken that includes you and/or your son/daughter and which is used in either video or printed publication. No names will be published or the individuals identified except in association with those who may know him/her.Please tick here to indicate your consent.

Tick

If it becomes necessary for you to receive medical treatment and no-one can be contacted by telephone or any other means to authorise this, please tick the appropriate box to indicate your consent to any necessary medical treatment and authosrise the event leader (or in their absence one of the assistant leaders) to sign any document required by the hospital authorities.*(This part particularly applies to under 16's where Parental consent is needed)

YES

NO

If it is considered necessary do you agree to mild painkillers (e.g. Paracetemol) being administered?(This part particlarlyapplies to under 16's where parental consent is needed)

YES

NO

If you accept responsibility to correctly and clearly label with the name and exact dosage any medication your child requires as well as hand the medication over to the leader before departure, please indicate by ticking the appropriate box.(Only fill this in if the application refers to child under 16)

YES

NO

Please indicate that you read and understood, and answered all previous questions appropriately to the best of your knowledge*

YES

Enter your name and date to indicate as signature and agreement to the above.*

Let's Go To Cape Town 16-30 Dec 2019