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School Traffic Survey 2017
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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