Parental Responsibility Declaration

In line with Department of Health Guidance, it is important that we hold a record of those people who have parental responsibility for all the children (under 16 years) registered with our practice.

By parental responsibility, we mean all the rights, duties, powers and responsibilities which by law a parent has in relation to a child. This will include any of the following:

The child’s mother
The child’s father if married to the mother at the time of the birth, or if they married after the birth.
The father if he co-registered the child’s birth with the mother and the registration took place after 1.12.2003
The father if he has registered a Parental Responsibility Agreement with the court
A civil partner:
- if she is in a civil partnership with the mother at the time of the birth
- if she registers a civil partnership with the mother later on,
- if she is on the UK birth certificate
- if she and the mother have signed a parental responsibility agreement, which is a prescribed form, and lodged it with the court; or
- if the court has made a parental responsibility order in her favour.
A person granted a court order under the powers of the Children Act 1989
A person who has been appointed a guardian by the court under the Children Act 1989

Please complete the attached form, letting us know who has parental responsibility for your child.

This information will be held on your child’s medical record. If there are any changes to the details, please let us know as soon as possible. If you have any queries, please email: info@thelondongeneralpractice.com.

Parent / Legal Guardian Details

Full Name(Required)

First Last

Date of Birth(Required)

Email address(Required)

Telephone number

Relationship to child

Child’s Details

Full Name(Required)

First Last

Date of Birth(Required)

Names of all people with parental responsibility and their relationship to the child:(Required)

Names of others who you have given written permission to bring the child for treatment (Nannies, Childminders, PA’s etc) together with their relationship to the child:

Please make sure that you inform us if any of these other people are no longer authorised so we can amend our records accordingly.

I confirm that I have parental responsibility for the above-named child and that I am happy that my child be treated if accompanied by any of the above-named people. I confirm that I will inform the practice immediately in the event of any change.(Required)

I confirm

Signature

Date(Required)

Signature