PARENT CONSENT/INDEMINITY FORM
FIELD WORK
(To be returned no later than date___1st August 2024___. Please note, your child/ward will be
permitted to participate in the proposed field work only if this consent form is signed and received on
or before the above-mentioned date.)
I have been informed of the trip to ___Shiv Nadar School, Noida __from 5th August to 6th August,
2024. I voluntarily consent to my child going on and actively participating in this Field work.
I am aware of this excursion, its objectives and the activities that my child might be participating in.
I have noted the details of transportation, accommodation arrangements (if required) and the
accompanying teachers. I also understand and acknowledge that there are inherent risks associated
with travel and stay (if required), which despite the due care taken in planning and executing this
programme may not be mitigated.
*(Provide information with details if the student has some medical concerns. Attach medical
certificate if required. Mark ‘N.A’ if not relevant).
Please give any other relevant information that you may feel is important.
By my signature, I voluntarily confirm satisfaction with the itinerary, arrangements and field trip
details shared with me.
Student Name & Grade : AVYUKT DEV GOEL, 9-B
Parent/Guardian name : BHARAT GOEL
Relationship to Student : Father
Email of Parent 1 : BG@conQuerent.in
Mobile #: 9899695910
Email of Parent 2 : Agrawal.meenu@gmail.com
Mobile #: 9811225110
Date : 31 July 2024 Signature of Parent
Contact information in case of an emergency
Name of contact person: BHARAT GOEL
Relation with the child: FATHER
Address: 9A Tower 26 Central Park Resorts Sec 48 Gurgaon
Email: BG@CONQUERENT.IN
Mobile: 9899695910 / 9899046810
Landline (with city code): 9899880803 Signature
_________________________________________________________________________________
____
Health Declaration of student
Blood group of your ward :___A+____________
Any visual impairment? Yes/ No/ Occasionally
Hearing loss? Yes/ No/ Occasionally
Any heart related condition or epilepsy? Yes/ No
Does your child have any health-related condition that would affect active participation on the
proposed field trip?
_____________________________________________________________________________
Allergic to any medication? _______________________________________________________
Any recent injury or surgery or any other serious illness or ailment? Yes/ No
If yes, please give details___________SORE THROAT & COUGH_______________________
Does your child have had any of the following or are you under medication for any of the following
conditions?
If yes, mention the health regime.
Allergies
________________________________________________________________
Asthma
________________________________________________________________
Influenza
________________________________________________________________
Diarrhoea
_______________________________________________________________
Infections (Malaria)(Dengue)
________________________________________________________________
Convulsions
________________________________________________________________
Joint pains
________________________________________________________________
Urinary infection/stone
________________________________________________________________
Menstrual issues
________________________________________________________________
Diabetes
________________________________________________________________
Hypertension
________________________________________________________________
Hepatitis
________________________________________________________________
Cardiac problems
_______________________________________________________________
Please mention any particular dietary requirements:
________________________________________________
Please give any other relevant information that you may feel is important.
Signature of the parent
