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Chipstead Place Lawn Tennis Club

CPF 3.1.10 - Trip and activity consent form

 

I do/do not (please delete as appropriate) give permission for my child:

 

_______________________________________________________ (child’s full name)

 

to attend the following trip/activity: __________________________________________

 

 

Signed

 

 

Date:

 

Name (please print)

 

 

Relationship to child

 

Address

 

 

 

 

 

Contact numbers:

 

 

Home

 

 

Mobile

 

 

Work

 

Email address

 

 

         

 

Further emergency contact details, if different from above:

 

Name (please print)

 

 

Relationship to child

 

Address

 

 

 

 

 

Contact numbers:

 

 

Home

 

 

Mobile

 

 

Work

 

Email address

 

 

 

Please use the box below to describe any special care needs, dietary requirements, allergies or medical conditions:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

In the event of a medical emergency, I give my consent for the group leaders to seek qualified medical assistance at their discretion and for them to give permission for emergency medical treatment / procedures to be administered/carried out if so advised by the emergency services or medical profession in the interests of the safety and protection of your child.

 

Signed: ____________________________________________________________________

 

Parent/Guardian: _____________________________________________________________

 

Relationship to child: ___________________________________________________________

 

 

Please return this form to:

 

Name (please print)

 

Address or instructions for returning form

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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