Bexleyheath District Cub Scouts In Case of Emergency (ICE) and Health Form 2020/2021 (Please complete in BLOCK CAPITALS) Surname Date of Birth Forenames Postcode Scout Group 1St Baldwyns Park Scout Group School NHS No Religion Date of last Tetanus Injection He/She can swim 50m and stay afloat for 5 minutes in light clothing. Yes  No  He/She can swim under careful supervision Yes  No  Stage of swimming (Non Swimmer/Beginner/Poor/Average/Good)*please delete Home Address: In Case of Emergency (ICE) Contact 1 Name and Address: …………………………………………………………………… …………………………………………………………………. …………………………………………………………………… ……………………………………………………………………. …………………………………………………………………… ... Telephone……………………………………………………… Telephone………………………………………………………… Mobile Phone…………………………………………………….. Cub Scouts Email Address: Parents Email Address: ……………………………………………………………………. ……………………………………………………………………. Cub Scouts Mobile Phone: …………………………………. Parents Mobile Phone: ……………..…………………………. In Case of Emergency (ICE) Contact 2 Name and Address: In Case of Emergency (ICE) Contact 3 Name and Address: …………………………………………………………………. …………………………………………. …………………………………………………………………… …………………………………………………………………… …. …………………………. Telephone…………………………………………………..…..… Telephone……………………………………………………..…. Mobile Phone…………………………………………………….. Mobile Phone…………………………………………………….. Doctors Name: ……………………………………………………… Telephone: …………………………………. Address : …………………………………………………………………………………………………………………………. The information contained on this Form will be kept securely and in confidence by the ADC Cub Scouts and will only be used by the District Leaders and designated First Aiders at District Events and Activities. A 2nd copy will be kept securely by your son or daughter’s own Cub Scout Leader. Please inform the ADC Cub Scouts and /or Cub Scout Leader if any of the information given on this form changes. This form will otherwise be held to be valid and up to date until 30 September 2021 Additional Information required. Please Continue over the page. Page 1 of 2 Note: All activities will be run in accordance with The Scout Association’s safety Rules. No responsibility for the personal equipment/clothing and effects can be accepted by the organisers and The Scout Association does not provide automatic insurance cover in respect to such items. Additional Information required. Please Continue over the page. Page 2 of 2 Bexleyheath District Cub Scouts ICE and Health Form Page 3 of 2 The appointed Scouter or First Aider will give minor Medical treatment. If it becomes necessary for my child to receive more serious medical treatment (eg at Doctor or Hospital) 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 Event First Aiders to sign any document required by the hospital authorities. I will inform the Event Leader or Event First Aider if my son / daughter has been in contact with any infectious diseases within 3 weeks ahead of an event (e.g. Chicken Pox, Measles, Mumps, Rubella, Whooping Cough, Diphtheria, etc) I give my permission for my son / daughter to appear in photos taken at District Events and Activities which may then appear in the District newsletter or on the District website www.bexleyheathscouts.org.uk or in other displays at Scouting events (e.g. County AGM. / Scouting magazine) Full names will never appear on the website but if you don’t want your son / daughter to ever appear please delete this paragraph. I will inform the Cub Scout Leader if any of the information given on this form changes. Name of Parent/Guardian Signature Relationship to Young Person Date The Event Leader, designated First Aiders (or in their absence one of the assistant Event Leaders) may administer the appropriate minor treatment/precautions (as listed below) if required. Please delete any you do NOT want your son / daughter to receive or indicate any known adverse reactions. Headache: - Calpol 6+ or Paracetamol tablets or Similar Over The Counter Products ……………………………………………….. Stomach Upset: - Gaviston tablets or liquid or Similar Over The Counter Products …………………………………………………. Cuts & Grazes: - Plasters or Similar Over The Counter Products …………………………………………………………………….. Colds etc.: - Calpol 6+ or Paracetamol or Similar Over The Counter Products ………………………………………………………. Sunburn, Nettle Rash etc: - Calamine lotion or Similar Over The Counter Products...……

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