Fitzwilliam Explorer Activity Form

Fitzwilliam Explorer Activity Form

Information and Consent Form This part to be kept by the parent/guardian. Please complete legibly in black ink.

Activity Date: - __________________ Please return the lower section of this form, completed and signed, to the Activity Leader by:

Is transport required? (Yes/No)_____________ Additional information_____________________ ______________________________________ ______________________________________ ______________________________________ ______________________________________

Name of Section: -Fitzwilliam Explorers Proposed Activity: - ______________________ ______________________________________ ______________________________________ ______________________________________

Home contact:-__________________________ ______________________________________ ______________________________________ ______________________________________

On (date)______________________________

Home contact phone:-____________________

At (place)______________________________ ______________________________________

Signed:-_______________________________ Leader’s Name:_________________________

Start time:-_____________________________

Date:__________________________________

Finish time:-____________________________ Cost:-_________________________________

 Cheques payable to:- Fitzwilliam Explorers

Parent’s or Guardian’s consent This part to be returned to the Leader

I have noted the arrangements and give permission for:(name of child)__________________________

I can provide transport (if yes please give details) ________________________________________ ________________________________________ ________________________________________ I enclose fee of £_____________________

To take part in (proposed activity): ______________________________________ ______________________________________ ______________________________________ Please state if your child has a disability or condition which might be affected by this activity: ______________________________________ ______________________________________ Please indicate details of any medical treatment she/he is having at the moment: ________________________________________ ________________________________________ ________________________________________ ________________________________________

I can be contacted during the day at: ________________________________________ ________________________________________ ________________________________________ Telephone Number:___________________ Signed:_____________________________ Name:______________________________ Date:_______________________________