"*" indicates required fields URLThis field is for validation purposes and should be left unchanged.Name of child/Individual:*Name of parent/guardian:*Name of FSW manager:*What is the rescue medication being used?*Below are areas that are to be shared by the parent/guardian to the support worker. Please could the questions and prompt boxes be complete, with the parent/guardian signing to confirm information given and the support worker signing to confirm information received. Allergies involved:*Parent/Guardian nameSupport Worker nameSigns & Symptoms present:Parent/Guardian nameSupport Worker nameHow and when to use the rescue med:Parent/Guardian nameSupport Worker nameAfter use instructions:Parent/Guardian nameSupport Worker nameEmergency details:Parent/Guardian nameSupport Worker nameIf you require more information or clarification on any of the details regarding this consent form please email info@familysupportwales.co.uk or carmarthenshire@familysupportwales.co.uk or your area office phone number: 01639 899978 or 01267 868041Supervisor/Senior Name*Supervisor/Senior Signature*Parent/Guardian Name*Parent/Guardian Signature*Date of consent* DD slash MM slash YYYY
