EXERCISE SHAPE UP - PCF & med form

ACP 17

6^th Edition

ACATI No 3

ANNEX B

CADETS PERSONAL DETAILS, MEDICAL CONSENT FORM AND

CERTIFICATE OF HEALTH

To be completed fully and signed by the person having parental responsibility or personally by a cadet over 18 years of age.

Cadets Surname:		Forenames:
Rank:	Male/Female:	ATC Sqn/ CCF Unit: 46F (Kensington) Sqn ATC
Date of Birth:		Religion:
Next of Kin/ Person to Contact:		Relationship:
Home Address: Post Code:		Telephone No:
Contact address and telephone number during the period of training (if different from above): Pippingford Trg Area, East Sussex. Contact No: Flt Lt C Butler 0790 568 5170 Post Code:

I wish to take part in adventure training activities at: Crowborough Trg Area from Fri 10 Mar 06 to Sun 12 Mar 06

Cadet Below the Age 18	Cadet Over the Age of 18
I give full consent to the above named cadet to take part in Air Cadet adventure training activities. I understand that he/she will be subject to Air Cadets care and discipline and must conform to appearance standards required, especially hair length. Permission is given to participate in full adventure training activities, I give permission to the Officer in Charge or his appointed representative to act as person in loco parentis should he/she have to undergo medical treatment including any emergency operation to which I am unable to physically give consent.	I understand that I will be subject to RAF care and discipline and must conform to appearance standards required, especially hair length. I wish to participate in full adventure training activities.
The information contained in this document is classified as sensitive personal information and is subject to the provisions of the Data Protection Act 1998. It is necessary for such information to be retained for legal reasons. Only such data as is relevant to the cadet’s attendance on adventure training activities will be used/retained. Signing below indicates your consent for us to use and retain such data. You have the right under the Data Protection Act 1998 to request access to any personal information we hold on the cadet.
Date Signed . Name in BLOCK Capitals . (Personal having Parental Responsibility)	Date Signed . Name in BLOCK Capitals . (Cadet over the Age of 18)

REGARDLESS OF THE CADET’S MEDICAL CONDITION YOU ARE REQUESTED TO COMPLETE FULLY, INCLUDING DOCTOR’S DETAILS, AND SIGN THE CERTIFICATE OF HEALTH OVERLEAF AND TO ATTACH ANY NECESSARY DOCUMENTATION TO EXPLAIN IN DETAIL A CONDITION FROM WHICH A CADET MAY SUFFER OF HAVE SUFFERED.

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ACP 17

6^th Edition

ACATI No 3

ANNEX B

SURNAME: ________________________ FORNAME(S): ________________________

CERTIFICATE OF HEALTH AND DECLARATION OF FITNESS

TO BE COMPLETED BY ALL CADETS AND ADULT STAFF

* Note: If any of the following do not apply insert “NONE” in the box(es).

1. * MEDICATION. I take the following medication:

Medication	Medical Condition

2.

Medical Condition/Past Injuries/ Allergies for which I do not take medication but may affect my performance during the activities.	Name, address and telephone number of the doctor I am registered with

3. Asthma. All cadets and adults must answer the following question:

Do you suffer or have you ever suffered from asthma? YES/NO

If YES then in addition to the declaration below you are to complete the questionnaire overleaf.

4. Declaration. I understand that I should be well prepared, physically and sufficiently fit to undergo strenuous activity. I have declared all medical matters that may affect my participation in the activities and I will inform the Officer in Charge of any additional medical matters that occur after the date of signing this form.

Signed:…………………………………………………Date:……………………………………………

Countersigned:…………………………………………

(Person having parental responsibility for a cadet under 18 years of age only)

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ACP 17

6^th Edition

ACATI No 3

ANNEX B

SURNAME: ________________________ FORNAME(S): _________________________

ASTHMATICS QUESTIONNAIRE AND DECLARATION – TO BE COMPLETED BY ALL CADETS AND ADULT STAFF WHO SUFFER, OR HAVE SUFFERED, FROM ASTHMA

* Delete as appropriate

1. Questionnaire. I confirm that I *suffer/have suffered from asthma and wish to declare the following information:

a. When was your last attack?:………………………………………….………………………….…

b. What preventative medication/inhalers do you use? (Include strength and frequency of dose……………

c. What reliever medication/inhalers do you use? (Include strength of dose):

Indicate frequency of use during normal daily activities e.g. once a day, once a week etc: ……………………………………………………..…………………………… …………………... ……………………………………………………………….

Indicate frequency of use during routine exercises……………… …………………………..… ……………..…………………………………………………………

d. Have you ever required hospital admission for your asthma? * YES/NO. If YES give details of when:……………… ……………………… …………………………………………………….. …………………………………………………………

e. Have you sought advice from your doctor or asthma nurse prior to completing the health declaration? *YES/NO. If YES what did your doctor or asthma nurse advice?...................... ..........................................................

Any Additional Comments:………………………………………………………………………....

………………………………………………….

2. Declaration. I fully understand that adventurous training is a strenuous activity, which may be undertaken in extremely cold and additionally, at times, in a “freezing fog” type atmosphere. Additionally, I confirm I have been advised that, if I am unsure about my fitness to take part in adventure training I should consult my Doctor or Asthma Nurse, before signing this Certificate and Declaration. Should my asthmatic condition change, requiring any amendment to the above questionnaire, before arriving for the activities, I undertake to advise the Officer in Charge, or if the change occurs during my participation in the activities.

Signed:…………………………………………………Date:……………………………………………

Countersigned:…………………………………………

(Person having parental responsibility for a cadet under 18 years of age only)

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