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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

Mobile

Email

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
operations)
Please include below details of any medicines being taken, any allergies e.g. penicillin, plasters etc or special dietary or other
treatment necessary
Medicine/Tablets
Allergies
Dietary requirements
Other treatment
His/Her National Health Service Medical
Card No (if known):
His/Her doctor’s name and surgery
address

Doctor’s telephone numbers
Any Religious needs

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