Stewart Island Medical Consent Form
To be completed by all parents/caregivers. Information submitted in this form is confidential to the Principal and trip supervisors
Email *
Dates 18th-22nd September  
Childs Name *
Contact Information
Address *
Home Phone *
Work Phone *
Mobile *
Email *
I agree to my child participating in this excursion *
Medical Check
Family Doctor *
Family Doctor Phone *
Specialist (if necessary) *
Relevant Medical History
Please underline any of the following list from which your child suffers and provide the class teacher with any further necessary information. This will remain confidential and we hope this will enable each child to fully enjoy the excursion, rather than stay away because of uncertainty or embarrassment. This information may be given under separate cover if so desired, or you may visit the school to discuss the matter.
Medication required - Please specify
Asthma: Please include attack plan
Does your child suffer from the following? *
Yes
No
Brochitis
Hayfever
Sinus
Headaches
Bed wetting
Sleep walking
Diabetes
My child can take the following medication *
Yes
No
Panadol Tablets
Liquid Panadol
Antihistamine
Ibuprofen
Allergies (please specify)
My child has had the series of three tetanus injections *
Last injection date *
MM
/
DD
/
YYYY
Other medical notes
Additional Remarks
In the event of accident or illness I authorise the obtaining of such medical assistance as may be required. I certify to the best of my knowledge, my child has not been in contact with any infectious disease for the last four weeks and has no physical disabilities likely to prove detrimental to him/herself or others during this excursion. *
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