Parental Consent Form for a field studies visit to Barcelona

Name of Organisation ________________________________________________

Event ______________________________________________________________

Date/Time from ____________________ to _______________________

Leader(s) in charge __________________________________________________

Name of Child / Young Person __________________________________________

Home Address ______________________________________________________

Telephone Number(s) _________________________________________________

Date of Birth________________

Passport No. ________________________

Doctor's name and address __________________________________________

Doctor's Telephone ________________________

Date of last anti-tetanus injection (if known) ______________________________

Has he/she been in contact with any infectious disease within the past three months? Yes No
Is he/she taking any medicine that needs to be continued during the visit? Yes No
Does he/she suffer from any allergies, recurrent illness, bad period pains or other illness or disability? Yes No

Other relevant medical details:__________________________________________

Special dietary requirements:___________________________________________

I have been notified of the travel arrangements and the rules for the visit.
I have seen the programme of events.
I have been notified of the name and address of our child's hosts.
I agree to reimburse the organisers for any out-of-pocket expenses incurred in dealing with difficulties or incidents for which my child is responsible, including accompanying my child back home following serious misconduct.

I hereby give consent for the child named above to take part in the activities of the event named above. In the event of a medical emergency I authorise the Leader named above to sign any consent form considered necessary by hospital authorities, if the delay required to obtain my own consent is considered inadvisable by the doctor or surgeon concerned.

En el caso de una emergencia médica que autoriza a la líder llamado anteriormente a firmar cualquier formulario de consentimiento se considera necesario por las autoridades del hospital, si la demora necesaria para obtener mi consentimiento se considera no aconsejable por el médico o cirujano en cuestión.

Signed ______________________________________________Parent / Guardian

Name ______________________________ Date ___________