PARENTS / CARERS CONSENT FORM

TO BE COMPLETED BY ACTIVITY ORGANISER AND KEPT BY THE CLUB CHILD WELFARE OFFICER

Activity

Dates:

Times:                                                              Venue:

TO BE COMPLETED BY PARENT / CARER

Childs name:                                                                 Date of Birth;      /         /

Home address:                                                             Emergency contact:

Tel:                                                                               Tel:

NB  please use the space below to advise the EIHA  and Club whether your child :

¨      Suffers from any illness or medical condition

¨      Is receiving medication – give details and dosage

¨      Has any specific dietary requirements

¨      Will  need help dressing/ undressing, going to the toilet etc.  Please note that if such help is necessary and you are unable to provide it, your signature below will indicate consent to the activity organiser making the necessary arrangements

I consent to my child receiving any medical treatment thought necessary by a qualified medical practitioner.

My child’s NHS number is:                                           GP name

                                                                                    Tel;

I  do / do not  consent to the taking of Photograph and or video during match play of my child and the team while playing Ice hockey and also for the use of such in official publications relating to the Hockey Club.   

Signed:                                                 parent/carer    date:

Print name: