1st Rustington Explorer Scouts
Event Selection
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Venue:
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Departure:
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Participant Details
First Name *
Surname *
Date of Birth *
Age *
Emergency Contacts
Contact Name *
Relationship *
Full Address *
Home Phone
Mobile Phone *
Doctor's Name
Doctor's Telephone
Medical Information
Does the participant suffer from any of the following?
Chest Complaints
Asthma
Hay Fever
Migraines
Diabetes
Anxiety
Disorders
Other medical conditions or disabilities?
Date of Last Tetanus
Infectious illnesses in the last month?
Yes
No
Receiving medical treatment at present?
Yes
No
Allergies?
Yes
No
Can swim 50m and tread water?
Yes
No
Consent for Paracetamol / Ibuprofen / Antihistamine?
Yes
No
Authorise EPIPEN medication?
Yes
No
Consent & Declaration
Parent / Guardian Name *
Parent / Guardian Email *
Relationship to participant *
Do you consent to EpiPen administration (where prescribed)?
Yes
No
Consent for paracetamol, ibuprofen or antihistamine?
Yes
No
I give consent for the young person named above to attend the event and participate in a variety of scouting activities in accordance with safety rules.
No responsibility for personal equipment/clothing and effects can be accepted by the organisers.
The Camp Leader reserves the right to send anyone home in case of dangerous or poor behaviour.
I give permission for the designated First Aider to administer appropriate medication. If medical treatment becomes necessary, I give general consent to any necessary medical treatment.
Signature & Submission
Date of Signature *
Your Signature *
Clear Signature
By submitting this form, you agree that this electronic signature is legally binding and that all information provided is accurate to the best of your knowledge.
