Millisle Primary School & Nursery

P4 Peace Plus Programme December 2025

Child's First Name

Child's Surname

I consent to my child taking part in this activity.

Any current medical condition ( if none, please state NONE)

Post medical condition e.g. following a medical procedure or illness (if none, please state NONE)

Any medication being taken (if none, please state NONE)

Any other relevant information which may affect his/her participation in the event, including allergy or dietary requirements ( if none, please state NONE)

Parent/Guardian Name

Parent/Guardian Number

I accept the established code of conduct for the visit and agree to the arrangements relating to my son/daughter returning home from the visit due to unforeseen circumstances.

I agree to my son/daughter receiving emergency medical treatment, including anaesthetic/ blood transfusion, as considered necessary, by the medical authorities present. I understand the extent and limitations of the insurance cover provided.

Password - completed forms will only be accepted from parents/guardians using the correct password. The recognised password will be sent to parents/guardians who are connected to Class Dojo. Please type the password as given to you.

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P4 Peace Plus Programme December 2025

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