Wednesday May 5, 2021
For National Pony Club updates and information please go to pcuk.org
Medical Form for camp

DINAS POWYS PONY CLUB CAMP 2018

CONFIDENTIAL

Information on Members / Associates attending Pony Club Camps, Courses or Visits

This form is to be completed by the Parent / Guardian of each Pony Club Member.

 

Name of Member / Associate ______________________________ Date of Birth __________

Name of Parents / Guardian ____________________________________________________

Authorised contact if parent unattainable _________________________Tel. No.__________

Address of Parents / Guardian __________________________________________________

____________________________________________________________________________

Tel. Number (Day)______________________________(Night) _______________________

Fax Number ___________________________Email__________________________________

Member’s General Practitioner NAME____________________________________________

Address of practice ___________________________________________________________

Does he / she suffer from:

* Asthma                                 YES / NO                   * Epilepsy / Fainting              YES / NO

* Migraine                               YES / NO                   * Diabetes                               YES / NO

* Dyslexia                               YES / NO                   * Hay Fever                            YES / NO

* Heart / Lung Disorder          YES / NO                   * Bone / Joint Impairment      YES / NO

* Vision / Hearing Defects     YES / NO                   * Allergy to Drugs / Food       YES / NO

* Gynaecological Disorders    YES / NO                   * Ear, Nose & Throat             YES / NO

* Gastro-intestinal Disorders YES / NO                   * Any skin complaint             YES / NO

Are contact lens worn ?___________  Religion, if applicable to Medical Treatment _________

Any other problem of which the Welfare Officer should be aware? _____________________

____________________________________________________________________________

Does he / she regularly take any form of Medication, if so what? ________________________

Are there any current injuries / recent operations / medical treatments? YES / NO If so, please explain.

Any previous operations, e.g., appendix                     YES / NO If so, please explain

Date of last Tetanus Injection _______________________________ (Any adverse reaction?)

Blood Group (if known) __________________________ Is he / she a Vegetarian YES / NO

Does he / she have any special dietary or other requirements? __________________________

In the event of my daughter/son requiring emergency medical or dental treatment whilst taking part in the Pony Club activity as described above, and an Officer or other responsible adult being unable to contact either myself or other person with a parental responsibility for my daughter/son, I hereby authorise the District Commissioner or other Officer of the Pony Club to obtain such medical or dental treatment for my child as they, in their absolute discretion, think necessary after consultation with a medical or dental practitioner. This authority extends to all medical and dental treatment including the giving of an anaesthetic where necessary.

I give permission for my child to be given plasters or paracetamol if needed

 

Signed ______________________________ Date __________________________________