DofE Gold Consent Form 2024 • Knole Academy

Name *

First

Last

Date of Birth *

Gender *

Address *

Mobile Number of Applicant *

Emergency Telephone Number *

Email Address of Applicant *

Please state any allergies e.g. aspirin, antibiotics, foods etc. *

Please explain any illness (including asthma), condition or disability *

Explain any contact with any contagious diseases in the past month *

Explain any injuries during the past month *

Please state any medication that has currently been prescribed or being used *

Is your child immunised against Tetanus? (please state the approximate date) *

Doctor's Name *

Doctor's Address *

Doctor's Telephone Number *

Declaration *

I confirm my son/daughter is capable of taking part in all of the activities as described

Declaration *

I confirm my child is willing to participate in the DofE Gold award level scheme

Illness/Injury *

In the event of illness or injury I agree to authorise members of staff during the course to consent on my behalf for an anaesthetic to be administered or any other urgent medical treatment upon the advice of a qualified medical practitioner

Photographic Consent *

I give permission for my child to be photographed

Photographic Consent *

I give permission for my child's photo to be placed across Knole Academy's social media channels

Name of Parent/Guardian - Full Name *

First

Last

Signature of Parent/Guardian *

Date *

Volunteering activity - What are you planning on doing? Where it is occurring? Who will the assessor be (not related to you)? and either an email or phone number for the assessor *

Physical activity - What are you planning on doing? Where it is occurring? Who will the assessor be (not related to you)? and either an email or phone number for the assessor *

Mobile (please or

Skills activity - What are you planning on doing? Where it is occurring? Who will the assessor be (not related to you)? and either an email or phone number for the assessor *