Trip Letter - Lea Green Y1

Here is the consent form for our Lea Green Trip 

Day visit - Consent form

This form must be completed and returned to Lea Green Centre staff
prior to your child / young person being allowed to participate in any activities.

 

Child’s name: _________________________________ Date of birth: _____________  Age: ______

 

Address: _________________________________________________________________________

 

_________________________________________________________________________________

 

Group name / date of visit: __Netheredge Primary School_________________________

 

Emergency Contact

 

Name: _____________________________________           Tel no: __________________________

 

Address: _________________________________________________________________________

 

________________________________________________________________________________

 

Medical Information

  1. Does your child / young person have any conditions requiring medical treatment, take any medication regularly or have any dietary requirements? YES /  NO

 

If yes, please give details _______________________________________________________________

 

___________________________________________________________________________________

 

  1. Name and address of your family doctor: _______________________________________________

 

___________________________________________________________________________________

 

Doctor telephone number: ______________________________________________________________

 

Declaration

I am aware that a day visit to Lea Green Centre will include adventurous activities and therefore has inherent risks. The activities may include High Ropes/Team Swing or Low Ropes activities, rock scrambling or stream walks. I confirm that my son / daughter/ child has no pre-existing medical condition that would prohibit him / her from taking part in an adventurous activity.

 

My son / daughter / child will receive appropriate safety briefings but must be aware of the need to follow instructions and to behave in a safe and sensible manner.  

 

I give consent for any filming or photographs taken of my son / daughter during their stay at Lea Green to be used for publicity purposes by Derbyshire Outdoor Education Service and Derbyshire County Council.

 

Please note: participants are not covered by a personal accident policy.  Parents / guardians who may wish to arrange this cover are asked to consult their own insurance company. Participants are provided with a recommended kit list. Please make sure that all personal belongings are clearly marked with the participant’s name. It is not advisable to bring valuable items. Any items brought to the Centre will be held at the individual’s own risk and the Centre will not be held responsible should they be lost or damaged. The use of mobile phones is prohibited when taking part in activities.

 

Name: ________________________________________   Signed: ___________________________

(Please print)                                                                           Date:     ___________________________

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Sheffield

S7 1RB

Tel: 0114 255 0926