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2019 Camp Dunedin - Child Health Form
Please complete a separate form for every child attending camp. The information on this form will be shared with all LAs attending camp. It will be used to ensure the health needs of your child will be met and in a case of emergency.Feel free to also discuss health needs/concerns with any of the LAs attending camp.
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* Indicates required question
Name of child
Your answer
Please tick if the student experiences any of the following:
*
Migraine
Diabetes
Epilepsy
Travel sickness
Chronic nose bleeds
Colour blindness
Heart condition
Sleepwalking
Anxiety
Bed wetting
Dizzy spells
Asthma
Fits (of any kind)
No health concerns to be aware of
Other:
Required
Is the child currently taking any medication?
*
Yes
No
If you answered 'yes' to medication, please specify the name of medication, the dosage and the time to be taken and the adult responsible for administering this medication :
Your answer
Has the child had any major injuries (breaks or strains) or illness (glandular fever etc) that could effect their ability to participate in activities?
*
Yes
No
If you answered 'yes' to injuries or illness please explain below:
Your answer
Is the child allergic to any of the following?
*
Medication
Food
Insect bites/stings
No allergies to be aware of
Other:
Required
If you answered 'yes' to allergies, please specify the allergy and the treatment required as well as who has this treatment onsite: i.e Bob is allergic to bees and I have his epi pen on me at all times.
Your answer
Is the child's tetanus up to date?
*
Yes
No
Other:
Please outline any dietary requirements:
*
Vegetarian
Vegan
Gluten Free
Dairy Free
Egg Free
No food allergies to be aware of
Other:
Required
Can we give pain/flu medication if necessary?
*
Yes - Panadol/Nurofen
No
Other:
To the best of your knowledge, has the child been in contact with any contagious/infectious diseases in the past four weeks? If 'yes' please explain:
*
Your answer
Is there any other information the staff should know to ensure the physical and emotional safety of the child? (e.g. cultural practices, anxieties, phobias)
*
Your answer
Medic Alert Number (if applicable):
Your answer
Please tick that you agree to these conditions (by agreeing to them you are "signing" this form):
*
I agree that if prescribed medication needs to be administered, a designated adult will be assigned to do this. I will ensure that prescribed medication is clearly labelled, securely fastened and handed to the designated adult with instructions on its administration.
I will inform the school as soon as possible of any changes in the medical information or other circumstances between now and the commencement of the event.
I agree to my daughter/son myself receiving any emergency medical, dental, or surgical treatment, including anaesthetic or blood transfusion, as considered necessary by the medical authorities present.
Any medical costs not covered by ACC or a community service card will be paid by families.
Required
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