Health Information Form

Health Information Form
Event Name
Section (Squirrels, Beavers, Cubs, Scouts & Explorers)

About the Young Person...
Young Person's Full Name
First NameLast Name
Young Person's Preferred Name (if different to above)
First NameLast Name
Young Person's DOB
DayMonthYear
Date of Birth
Young Person's NHS Number (If known)
Date of last Tetanus Injection (If known)
DayMonthYear
Date
Date of last MMR Injection (If known)
DayMonthYear
Date
Young Person's Home Address
Address Line 1
Address Line 2
CityTown
Postcode
Accident form link URL
Medication Log form link URL

Parent/Guardian Information
Parent/Guardian's Full Name
First NameLast Name
Relationship to Young Person
Parent/Guardian's Home Address
Address Line 1
Address Line 2
CityTown
Postcode
Same as Young Person?
Contact Phone Number 1
Contact Phone Number 2
Phone Number 2 cannot be the same as phone number 1... please provide two DIFFERENT phone numbers.
Text Message Phone Number
Format: 07000000000.
Parent/Guardian's Email Address

Medical Information
Part 1 of 2
If it becomes necessary for the Young Person named above to receive medical treatment and I cannot be contacted by telephone or any other means to authorise this, I hereby give my general consent to any necessary medical treatment and authorise the Event Leader or Deputy Event Leader to act on my behalf.
GP Surgery
Surgery Name
GP's Name
First NameLast Name
GP Surgery's Address
Street Address
Street Address Line 2
CityTown
Postcode
GP Phone Number
Format: 00000000000.
Allowed treatments for Headache
Please list above any treatments which the event leader (or in their absence the deputy event leader) may administer for a headache during the event.
Allowed treatments for Stomach upset
Please list above any treatments which the event leader (or in their absence the deputy event leader) may administer for a stomach upset during the event.
Allowed treatments for Cold/flu
Please list above any treatments which the event leader (or in their absence the deputy event leader) may administer for a cold/flu during the event.
Other Allowed treatments
Please list above any other treatments which the event leader (or in their absence the deputy event leader) may administer during the event. (Eg. Imodium, hay fever tablets etc.)

Medical Information
Part 2 of 2
Any known infection diseases with which they have been in contact in the three weeks previous to the signing of this form
(E.g. Chicken Pox, Diphtheria, Measles, Mumps, Rubella, Whooping Cough, Covid-19 etc.) Please write the word 'None' if no details needed
Any known allergies / sensitivities / disabilities and details of any known precautions or remedies.
(E.g. Penicillin, Food Colourings, Face Paint, Travel Sickness, Bed-wetting, Asthma etc.) Please write the word 'None' if no details needed
Details of any known (or under investigation) medical conditions.
(E.g. Diabetes, Heart Conditions, Kidney failure, ASD, ADHD, Anxiety etc.)
Details of any medicines / treatments currently being taken / followed (including dosage details) and the specialist & hospital concerned if appropriate.
(Please include any non-prescription preparations, such as cough sweets, herbal medicines etc).(If He / She has to take any medicines, the bottle(s), jar(s) or other items must be clearly labelled with their name and the exact dosages, and the Event Leader MUST be informed on arrival.) Please write the word 'None' if no details needed
All medication should be handed in to a leader at the start of the event.
Please label clearly with the child's name, dosage and timings.
Details of any specific dietary requirements:
(e.g. Vegetarian, Vegan, Lactose intolerance, Gluten free etc) Please write the word 'None' if no details needed

Additional information
Specific Transport arrangements - Please check with event lead first.
Eg. Arriving late, leaving early etc. (Please agree above with event leader first)
Additional information you think we may need
Please provide as much detail as possible.

Data protection
The Scout Association is committed to the Data Principles of the General Data Protection Regulation and the Data Protection Act 2018.
By signing this form, I agree to the Group during and beyond my young person’s involvement with the organisation:
a) retaining personal data to facilitate any present or potential future involvement with Scouting, in line with the local Group Data Protection and Retention Policy.
b) retaining sensitive (special category) data regarding religion/faith, disabilities/additional needs, ethnicity, medical information and/or commission of offences or alleged offences, in line with the Group Data Protection and Retention Policy.
c) allowing access to personal data to appropriate individuals within the hierarchy of Scouting.
d) allowing this information to be printed out and taken on camp to aid the leaders in their duty of care for the young person named above and understand that this information will be kept secure and confidential throughout the event.
e) allowing this information to be shared with any medical professional (ambulance, doctors, dentists etc) to provide the best care possible in case of injury or other emergency while away on camp.

Injury, Illness & Home Sickness while away
Sometimes during nights away events a young person needs to go home part way through, whether this be due to injury, illness, general home-sickness or any other reason as deemed necessary by the Event Lead or Deputy.
By signing the below, I agree that I will ensure that I (or someone I trust) will be available throughout the event to come and collect my child should they need to go home early. If I am not in a fit state to drive to collect my child, I accept that the cost of transport services (such as Uber or similar) will be at my own expense.
Yes, I agree
Parent/Guardian Signature (please sign in box below)
Should be Empty:

Health Information Form

About the Young Person...

Parent/Guardian Information

Medical Information

Medical Information

Additional information