Untitled Survey - Dapto Public School

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2015 Canberra Overnight Excursion - Medical Consent Form

Program Details:

Canberra Overnight Excursion 2015 Date: 11/11/2015 to 12/11/2015

Participant Details:

* Indicates required field

Name *

First

Last

Select Gender: *

Male Female

Date of Birth (dd/mm/yy) *

YEAR 5
DAPTO PUBLIC SCHOOL
66 Sierra Drive, HORSLEY, NSW, 2530

Parent / Caregiver Contact Details:

Name *

First

Last

Address *

Untitled *

Suburb *

State *

Postcode *

Home Phone *

Mobile Phone *

Work Phone *

Fax Number *

Email *

Relationship to Participant *

Parent Caregiver Grandparent Family Member

Allergies and Special Diets:

If your child has a special dietary need please provide information using the categories below:

1) Food Related anaphylaxis diagnosed by a doctor *

YES - An ANAPHYLAXIS ACTION PLAN and at least ONE adrenaline auto-injector MUST be provided NO - (Continue to next question)

Please indicate the item /s your child CANNOT eat *

Peanuts Tree Nuts Egg Wheat Sesame Crustaceans Fish Milk Soy Sulphites (Specify below) Other (Specify Below)

Other/Further Information: *

2) Allergy or Intolerance *

YES - Particular foods can cause discomfort & illness, but are NOT life-threatening. NO - (continue to next question)

Please indicate the item/s below your child CANNOT eat *

Peanuts Tree Nuts Egg Wheat sesame Fish Milk Soy Gluten Lactose/Dairy Yeast Food Additives (Specify Below) Sulphites (Specify Below) Other (Specify Below)

Other / Further Information: *

3) Aversion / religious beliefs / lifestyle choice: *

YES - You or your child have made a decision not to eat these foods, or to eat certain types of foods. NO - (Continue to next question)

Please indicate your child's special diet: *

Vegan Vegetarian No red meat No beef Halal Kosher Other (Specify Below)

Other / Further information: *

4) Non Food related allergy *

YES - A doctor has diagnosed my child with a non-food related allergy NO - (Continue to next question)

Please indicate your child's non-food related allergy *

Insect bite / sting (Specify below) Medication (Specify Below) Other (Specify Below)

Other / further information: *

Has he/she been prescribed an adrenaline auto injector (Epi-pen / Ana-Pen) *

Yes No

Has he/she been hospitalised with a severe allergic reaction? *

Yes No

Does he/she have an ASCIA ACTION PLAN for anaphylaxis? *

Yes No

Children diagnosed with anaphylaxis MUST have an ASCIA ACTION PLAN & at least one auto-injector.
(Please forward ASCIA Action Plan to the school as soon as possible)

Health Details & Related Information

Does the participant suffer from the following (Please forward details to the school as required) *

A current illness A disability / chronic illness Asthma (provide asthma plan to school) Bed wetting Attention deficit disorder (ADD?ADHD) Behavioural problems Diabetes Epilepsy Sleep walking Skin condition Other (Specify below)

Other / Further information: *

Has he/she had the Combined Diptheria Tetanus Toxoid booster injection? *

Yes No

Has he/she been immunised against measles? *

Yes No

Year booster given *

Year of measles immunisation? *

Private health insurance fund: *

Member Number: *

Medicare number: *

Position on card: *

Valid till: *

Current Medication:

Please list Time & Dosage of any Medication Needed:
(Please specify exact time of medication - forward any further details to the school as required):

Name of Medication *

Time to be given *

Choose One *

am pm

Dosage *

Name of Medication *

Time to be given *

Choose One *

am pm

Dosage *

Name of Medication *

Time to be Given *

Choose One *

am pm

Dosage *

I confirm that the information on this form is correct at the time of completion,

Signature: (Please type name below to indicate signature) *

Date: (dd/mm/yy) *

Submit

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