Student Scout and Guide Organisation
Please complete 2 copies of this form: 1 to be handed in, 1 to be carried with you.
Name
   Date of Birth
Home Address

Post Code
Telephone Number
  Term Time Address

Post Code
Telephone Number
National Health Number
   Date of Anti-tetanus
Doctor's Details
Doctor's Name
Surgery Address

Post Code
Telephone Number
  Emergency Contact
Name
Address

Post Code
Telephone Number
Please Give Details of:
Any medical conditions(e.g. Asthma, diabetes etc.)
Any medication being taken at present
  
Any allergies to medication
Any other relevant information
EMERGENCY TREATMENT
In the event of being unable to make a decision I DO/DO NOT give my permission for the event organiser or their appointed First Aider to sign for emergency treatment deemed necessary by a doctor on my behalf.


Signed:
Date: