EV2 CONSENT FORM (for Educational Visits) - Leeds City College

EV2 CONSENT FORM (for Educational Visits)(If participant is over 18 or aged between 16 - 18 and designated independent, they can sign forthemselves)(Group Leader to assist participants in completing Section 1 in conjunction with details of visit)1. Details of Visit(s)Course or Activity: FdA Leadership and ManagementName and Address of Place(s) to be Visited:Leeds City College – Horsforth CampusDate of Visit:Wednesday 11 th September2. Details of ParticipantParticipant’s Name:Date of Birth:Residential Address:Contact Telephone:Please tick as appropriate Participant Staff Volunteer 3. Medical Informationa. Participant’s Medical Number:b. Does your participant suffer from any of the following:Please tick as appropriate Asthma Diabetes Hay Fever Epilepsy c. Are there ANY OTHER CONDITIONS which Leeds City College and Staff need be aware of, or which may requiremedication / treatment?YES / NOIf YES, please give details, including medication taken.d. To the best of your knowledge, has the participant suffered from or been in contact with any contagious orinfectious diseases or anything in the last four weeks?YES / NOIf YES, please give brief details:e. Has the participant had any serious injuries that have required treatment within the last twelve months?YES / NOIf YES, please give details:f. Is the participant allergic to any medication? YES / NOIf YES, please specify:g. Has the participant had a tetanus injection in the last five years? YES / NOIf YES, please specify:h. Please outline any special dietary requirements of your participant.i. Details of Family DoctorName:Surgery Address:Daytime Contact Number: Out of Hours Contact Number :

4. For Swimming Activities or Activities Where Being Able To Swim Is EssentialIs the participant:(please delete as appropriate)- Able to swim 2 lengths of a 25m pool (50 metres)? YES / NO- Water confident in a pool? YES / NO- Confident in the sea or in open inland water? YES / NO- Safety conscious in water? YES / NO- In good health and I consider him/her fit to participate in water activities? YES / NONB: Consent does not remove the need for Group Leaders to ascertain for themselves the level of the participant’sswimming ability.5. Emergency Contact Information(i.e. contact number, relationship e.g. mother, spouse etc)Contact 1 (Please indicate whether work or home number)Name:Relationship to participant:Daytime Contact Number: Evening Contact Number :Contact 2 (Please indicate whether work or home number)Name:Relationship to participant:Daytime Contact Number: Evening Contact Number :6. DeclarationParticipantI agree to behave in a safe and appropriate manner at all times.Name: Signature: Date:(please print)Parent / Guardian / CarerI have read the information provided, understand the associated risks, and agree to the participantvia the method of transport indicated, and participating in the activities described for this visit.travellingI also agree to the participant receiving medication or emergency medical treatment, including anaesthetic or bloodtransfusion, as considered necessary by the medical authorities present.Name: Signature: Date:(please print)Relationship to participant, if not a MOS / Volunteer:(If not 18, or designated independent, then this form must be counter signed by a parent / carer)A full risk assessment for this activity/visit has been carried out and is available upon requestThe processing of this data is in compliance with the 1998 Data Protection Act.This form must be taken by the Group Leader on the activity, and a copy must be retained by the Collegeemergency contact person