Rock school 2 pg2 2011

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Rock school 2 pg2 2011

  1. 1. Camps Medical Form Special dietary requirements --------------------------------------------------------------------------------- ---------------------------------------------------------------------------------Allergies/Medical Conditions --------------------------------------------------------------------------------- Name of GP --------------------------------------------------------------------------------- Address of GP --------------------------------------------------------------------------------- Telephone --------------------------------------------------------------------------------- number of GP --------------------------------------------------------------------------------- Emergency Contact Name --------------------------------------------------------------------------------- 2 Emergency Contact No ---------------------------------------------------------------------------------Parent/Guardian Name ---------------------------------------------------------------------------------Parent/Guardian Contact No --------------------------------------------------------------------------------- Consent please tick to indicate agreement: I give permission for my child to attend this camp run by SWYM I give permission for my child to receive First Aid if deemed necessary by qualified personnel I give permission for my child to receive paracetamol/Ibuprofen if deemed necessary by qualified personnel Should my child be taken to hospital and you are unable to contact me, I give permission for medical personnel to intervene as necessary Signed: Date: Video and camera footage will be taken during the camp for use during Camp and for SWYM promotional opportunities. By sending a young person to this camp we are assuming your permission for photographs and video footage to be taken Data Protection: The details submitted on this form will be retained on the SWYM Camps database and will be used in distributing information of future camps & events, if you do not want to be sent any further information, please tick this box

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