Consent Form

Mallaig and District Canoe Club	CONSENT FORM & MEDICAL FORM For Juniors attending pool sessions/away trips (Based on Scottish Canoe Association recommendations)
It may be necessary for the adult accompanying your child to have the necessary authority to obtain any urgent treatment which may be required whilst away from home or taking part in canoeing activities. Would you therefore please complete all details and sign at the bottom to give your consent.
Junior’s name	Date of birth
Address		Post code
Phone no.	Mobile no.
Email address

Parent/Guardian Emergency Contact Details (if different from above)
Address		Post code

Phone no.	Mobile no.
Email address

Alternative Emergency Contact Details (other than parent or guardian above, in case you can’t be contacted)
Name	Relationship to Junior
Address		Post code

Phone no.	Mobile no.
Email address

I am aware of the nature of canoeing activities and agree to my son/daughter taking part in these activities. I confirm to the best of my knowledge that my son/daughter does not suffer from any medical condition other than those listed and will notify the Club should this situation change. I consent to my child receiving medical treatment, which, in the opinion of a qualified medical practitioner, may be necessary. I consent to the release of my son/daughter medical notes to a suitably qualified medical practitioner. I confirm that my son/daughter is not subject to any court order prohibiting publication of their image and give permission for them to be filmed/photographed undertaking canoeing related activities. I consent to my son/daughter travelling by any form of public transport, minibus or motor vehicle driven by a suitably qualified and insured volunteer to any event in which the club is participating. I agree to be at the pick-up/drop-off point at the agreed time. I understand that the club or organisers accept no responsibility for loss, damage or injury caused by or during attendance on any of the clubs organised activities except where such loss, damage or injury can be shown to result directly from the negligence of the club or the organisers. How information about your son/daughter will be used Personal information which you supply to M.D.C.C. may be used in a number of ways by both by us and the Scottish Canoe Association, the sports governing body, to which we are affiliated, for example: • to administer and manage your membership and related benefits. Your information will be held by us and by the SCA in a central membership database • to provide you with details of forthcoming activities etc. • we may pass your personal information to the insurer in the event of our club making an insurance claim By signing this form you agree that we may use and disclose your information for the purposes described above. If you have an issue with this for any reason please contact Joan at smith.joan@hotmail.co.uk. Benefits of affiliation Third Party Liability Insurance for recognised club activities Club details listed in the SCA Yearbook and on the SCA Website with link to our Club website www.mallaigcanoeclub.co.uk Right to organise events (with permission) under the auspices of the SCA Support and professional advice from SCA Staff Discipline specific advice from volunteers serving on SCA Committees Advice and help with paddling related queries via the SCA Office Help and advice on Child Protection and the processing of the relevant forms Affiliation to national governing body is a requirement for certain grant and funding applications

MEDICAL INFORMATION 1. Does your child have any medical condition requiring medical treatment and/or medication? (e.g. asthma, diabetes, epilepsy and other? If yes please give further information including names of medication, frequency taken and dosage. Please note that your child is responsible for the administration of their own medication.		YES/NO

2. Does your child, to your knowledge, have any allergies? (e.g. nuts, bee stings, latex, pollen etc.) If yes please give further information including any treatment or action usually required.		YES/NO

3. Does your child have any special dietary requirements? If yes please give further details		YES/NO

4. Does your child have any other medical or other conditions that may affect their ability to take part in canoeing and related activities that the Club should be aware of? If yes please give further details including any actions or further support your child needs to enable them to take part.		YES/NO
I, being the parent/guardian of the above named Junior, have read and agree with the above and consent to emergency medical treatment arising from any incident, including the administration of an anaesthetic if required.
SIGNED (Parent/Guardian) PRINT FULL NAME DATE