Section 1 – Tour Details

Tour destination:
Date from:
Date to:
I agree to my child taking part in the above tour and I have read the information sheet from the tour operator.
I agree to my child's participation in the activities described.
I agree to my child to behave responsibly.

Section 2 – Emergency Contact Details

Emergency contact 1:

Contact name:
Relationship:
Telephone (Mobile):
Telephone (Work):
Telephone (Home):

Section 3 – Doctors Details

Doctor's name:
Surgery name:
Surgery address:
Surgery telephone number:

Section 4 – Medical Information

Does your child suffer from any medical conditions (including injuries)? Please specify.
Does the condition require the administration of any medication? Yes / No, if YES please give details.
Do you give permission for staff to administer the medication if required? Yes / No.
Does your child have any allergies (including to medication)? Yes / No, if YES please give details.
Does your child have any specific dietary requirements? Yes / No, if YES please give details.
To the best of your knowledge, has your child been in contact with any contagious or infectious diseases in the last four weeks, or suffered from anything that might be contagious or infectious during that time?
Yes / No, if YES please give details.

Section 5 – Activities

Would you please read the information below so that we are sure that you are aware of the activities planned for Leicestershire County Cricket Club and that your child / children has your permission for these activities.
I agree to my child / children taking part in the activities below [please tick those that you do wish him / her to do]

Swimming in the hotel pool* with the permission and presence of Management Team
Participate in beach activities on the beach trips* with the permission and presence of Management Team
Swimming and / or water based activities* with the permission and presence of Management Team
Participate in the 4x4 safari during the desert safari* with the permission and presence of Management Team:
* denotes: Subject to specific risk assessments

Section 6 – Declaration

I agree to my child receiving medication as instructed and to any emergency dental, medical or surgical treatment, including anaesthetic or blood transfusion, as considered necessary by the medical authorities present. I understand the extent and limitations of the insurance cover provided. I will inform the Tour Leader / Leicestershire Country Cricket Club as soon as possible of any changes in my child's medical or other circumstances between now and the commencement of the trip.

Signature:
Print name:
Date: