Student medical form
To be completed by parent/guardian. Please use a parent/guardian email address.

The information provided is being obtained for the purpose of ascertaining relevant medical information, requirements and other health care related needs of students attending the SCMC. It will be used by officers of the NSW Department of Education to assist planning, to support students, and to minimise risks when conducting all activities related to the 2021 South Coast Music Camp

Other persons or agencies that may be provided with this information include, but are not limited to, volunteers and members of external organisations involved in the planning or delivery of the SCMC; and persons that may be called upon to provide health care treatment or other assistance during or as a consequence of such activities.

Provision of this information is not required by law. However, a failure to provide the information may mean that your child cannot participate in a particular activity. Provision of this information will significantly assist the SCMC in planning a safer educational activity.  It will be stored securely.

If you have any concerns about provision of this information, please contact Crystal Howarth.  You may correct any personal information provided at any time by contacting Crystal Howarth at crystal.jones19@det.nsw.edu.au.

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電子郵件 *
Student first name: *
Student surname: *
Student date of birth: *
Year: *
Parent/guardian name: *
Parent/guardian email: *
Parent/guardian mobile: *
(please input as XXXX XXX XXX)
Emergency contact name and mobile number *
(if parent/guardian unavailable)
Doctor name: *
Doctor contact number: *
Medicare number: *
(including number they are on the card)
Medical conditions
List existing medical conditions or illnesses (include existing and/or previous injuries, asthma, diabetes, epilepsy, allergies etc.). Outline the treatment for each.  Students who have a medical Action Plan must supply a copy with this form.  This includes but is not limited to Anaphylaxis and Asthma Action Plans.

ANAPLYLAXIS
Students who suffer from allergies which may lead to anaphylactic shock must forward a copy of their Action Plan attached to Crystal Howarth - crystal.jones19@det.nsw.edu.au

Students will also be required to see the First Aid Officer with applicable medication, epipen and another copy of their student action plan on arrival at Camp.

Does your child have any medical conditions? *
If answered YES to medical conditions please list conditions and treatment required:
Does you child have a medical action plan? *
Medications
Please list any medication(s) and dosage your child may be required to take during rehearsal/personal times.
I give permission for paracetamol to be administered to my child if required during the camp *
If answered YES above please advise dosage permitted to administer
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Dietary
Does your child have any dietary requirements? *
If answered YES please list dietary needs including possible reaction to inappropriate food
Parent/guardian confirmation
This information is correct as at the date of completing this form.  If there are any changes to this information I will contact Crystal Howarth with any additional information. *
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這份表單是在 NSW Dept of Education 中建立。 檢舉濫用情形
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