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Parental Consent Form
for De Montfort University Climbing Wall
Child’s Details
Age (on first day of Event) : Years__ _ Months ___
Date of Birth__ __ ___ __
First name

Last name

All details below to be compl eted by parent/guardi an
Parent/guardian name(s)
Work tel

Home tel



Emergency Contact Details
Full name

Emergency contact number

Medical Matters
Does your son/daughter have any medical
problems you feel we should know about?
(include all details about Asthma, Diabetes,
Epilepsy , recent investigations and relevant
Please include below details of any medicines being taken, any allergies e.g. penicillin, plasters etc or special dietary or other
treatment necessary
Dietary requirements
Other treatment
His/Her National Health Service Medical
Card No (if known):
His/Her doctor’s name and surgery

Doctor’s telephone numbers
Any Religious needs

Parental Consent
I am aware that climbing, hill walking and mountaineering are