Member’s name in CAPITALS
SPECIAL ACTIVITY CONSENT FORM
This form is to be completed for all residential activities involving a night away from home or for those activities which are not usually part of the
Company programme. This is to ensure that we have up to date personal information for all members including medical and emergency contact details.
This form should be completed and returned to the Company as soon as possible.
Please complete in BLOCK CAPITALS. Boxes marked with a * are compulsory.
Part A - to be completed by Leader
It is advised that Parents/Carers make a note of the details below:
Event/Activity:* Building Your Skills
Location:* Carmondean community Centre (West Barn) Nether Dechmont Farm, Livingston, EH54 8AX
Start Date/Time:* 1pm End Date/Time:* 5.30pm
Proposed Activity(ies):* Training Course
Leader in Charge (name):* Andrew Dalgleish
Part B - to be completed by Parent/Carer
Personal Details
Please complete details for the child/young person:
Surname:* First Name:*
Date of Birth:* / /
Address:*
Town:* County:* Postcode:*
Medical Details
Doctor/Surgery:* Surgery Address:*
Surgery Phone:*
Does the participant have any allergies?* No Yes (please provide details below)
Does the participant have any illnesses or disabilities relevant to this event/activity?* No Yes (please provide details below)
Continued
Is the participant currently taking medication?* No Yes (please provide details below)
Does the participant self-medicate?* No Yes
Please label participants’ medication with their name and provide clear instructions for its use (whether or not they self-medicate).
Has the participant been immunised against tetanus within the last five years?* Yes No
Please give details of any additional medical/health information leaders should be aware of:
Emergency Contact Details
Please provide details of the primary contact (usually parent/carer) and an additional emergency contact who will be contactable at all times during
the event/activity:
Primary Contact*
Title:* First Name:* Last Name:*
Relationship to BB Member:* Phone:* Mobile:*
Emergency Contact*
Title:* First Name:* Last Name:*
Relationship to BB Member:* Phone:* Mobile:*
Consent
The parent/carer is required to read and agree to all the following statements:
I give permission for my child to attend and take part in the event/activity(ies) stated overleaf.
I confirm that the information provided is correct to the best of my knowledge and undertake to notify the Leader in Charge of any changes.
I understand that in the event of any illness or accident, every effort will be made to contact me, but if this is not possible, I authorise Leaders to
give permission for my child to receive medical treatment as considered necessary by the medical authorities present.
Photo Consent
The photographic and video permissions you have given/updated through the Joining/Annual Information Form or My.BB will apply at this event/
activity. Should you wish to review or change this please speak to the Leader in Charge prior to the event/activity.
Signed:
Name:*
Relationship to BB Member:
Date: / /
Should you have any questions regarding this form or any other matter please speak to the Company Captain or Leader in Charge.
For more information about The Boys’ Brigade and our polices & regulations visit our website at boys-brigade.org.uk
A Registered Charity in England & Wales (305969) and Scotland (SC038016).
The Boys’ Brigade is a Company limited by guarantee, registered in England & Wales no. 145122.
Registered Address: Felden Lodge, Hemel Hempstead, Herts, HP3 0BL.
Leader’s Use
Form received: / / This form should be retained and stored securely for a period of 6 months following the event.
Ref: SpecialActivityConsent-0818
