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DofE Gold Consent Form 2021

DofE Gold Consent Form 2021 (Years 12 & 13)

First Name*
Surname*
Initials*
Date of Birth*
Gender*
Address*
Post Code*
Home Telephone Number*
Emergency Telephone Number*
Please state any allergies e.g. aspirin, antibiotics, foods etc.*
Please explain any illness (including asthma), condition or disability*
Explain any contact with any contagious diseases in the past month*
Explain any injuries during the past month*
Please state any medication that has currently been prescribed or being used*
Is your child immunised against Tetanus? (please state the approximate date)*
Doctor's Name*
Doctor's Address*
Doctor's telephone number*
I confirm my child is willing to participate in the DofE Gold award level scheme*
In the event of illness or injury I agree to authorise members of staff during the course to consent on my behalf for an anaesthetic to be administered or any other urgent medical treatment upon the advice of a qualified medical practitioner*
I give permission for my child to be photographed yes/no*
I give permission for my child's photo to be placed across Knole Academy's social media channels*
Name of parent/guardian*
Signature of parent/guardian*
Date*