LAN Party Parental Consent Form

Event Information

Venue:

Quality Hotel
Micheldever Road
Andover
Hampshire

SP11 6LA

Tel:
Hotel - 01264 369111
Event Mobile - 07833 392008
email: venue@roweb.co.uk

Event:

Post to this address or bring signed form with you on the day

RoWeb LAN Gaming Event

c/o M H Rowe
6 Little Woodfalls Drive
Woodfalls
Wilts
SP5 2NN

Contact Tel: 07833 392008

Event Organiser:

M H Rowe

Person Atending:

 


Authority

I , the undersigned, give my permission for the person attending to take part in the LAN Party being organised by
the Organiser listed above.

Health Information

This should be completed by the parent or guardian of the young person concerned. Please answer all the following
questions as fully as possible. In the event of them requiring emergency treatment, it will help the medical authorities in
deciding which is the most appropriate treatment to give.

(Please complete in BLOCK CAPITALS)

Surname:

 Date of Birth:

 

Forenames:

 National Insurance Number:

 

I wish to be informed at any hour is he/she is seen to consume alcoholic drinks: Yes / No

Date of last tetanus injection:

 

Parent/Guardian’s Normal Address:

 

Telephone

Family Doctor’s Name and Address:

If felt to be neccesary by Parents

Telephone

If felt to be neccesary by Parents

 

I hereby give permission for the person named above to attend the ‘LAN Party’ at the aforementioned event venue.

If it becomes necessary for them 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 an event organiser
named above, to sign any document required by the hospital authorities.

I will inform the event organisers if any of the information given on this form changes (in particular see items 1, 2 and 3 below/overleaf).

Name of Parent/Guardian :

Relationship to Young Person:

Signature:

Date:

The event managers may administer the appropriate minor treatment/precautions (as listed below) if required.

Headache: Yes / No

Upset Stomach: Yes / No

Cuts & Grazes: Yes / No

Colds etc.: Yes / No

Drunkenness : Yes / No

Other specific ailments:

 

In the space below please give details of the following:

  1. Any known infections diseases with which they have been in contact, within the three weeks previous to the signing of this form (e.g. chicken pox, diphtheria, measles, mumps, rubella, whooping cough, etc.).

  2. Any known allergies/sensitivities/disabilities and details of any known precautions or remedies (e.g. penicillin, food colourings, travel sickness, bed-wetting, asthma, etc.).

  3. Details of any medicines/diets/treatments currently being taken/followed (include dosage details) and the specialist and hospital concerned if appropriate (please include any non-prescription preparations, such as cough sweets, herbal medicines).

(If he/she has to take any medicine’s, the bottle(s), jar(s) or other items should be clearly labelled with their name and the exact dosages, and an event organiser informed on arrival)

Please continue on a separate sheet if required (remember to include the young person’s name on any separate sheets and attach them securely to this form).