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Year 5 Student Medical and Dietary Information
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* Indicates required question
Email
*
Your email
Student's First Name
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First Name
Your answer
Student's Last Name
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Last Name
Your answer
Student's Year Group
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Year
Your answer
Carer 1 - Name
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Full Name
Your answer
Carer 1 - Mobile Number
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Mobile Number
Your answer
Carer 2 - Name
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Full Name
Your answer
Carer 2 - Mobile Number
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Mobile Number
Your answer
Health
Please complete the following:
1. Does your child suffer from any major illness (including asthma), medical condition or allergies which could affect them while at camp? Please describe in detail, sending further information if necessary
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Yes - complete 1(a), 1(b) and 1(c)
No (insert n/a to Questions 1(a)-(c) if not relevant)
1(a) Illness/Condition
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Your answer
1(b) Describe likely symptoms / reactions
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Your answer
1(c) Outline a treatment plan.
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Your answer
2. Does your child require medication for this condition? NB Medication with instructions in a zip-lock bag is to be handed into School Nurse the week before departure for camp.
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Yes - complete 2(a), 2(b) and 2(c)
No
2(a) Name of Medication
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Your answer
2(b) Dose (strength in mgs/frequency)
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Your answer
2(c) Time of day to be given
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Your answer
Other Information
3. Date of last tetanus shot
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Your answer
4. Medicare and Reference Numbers
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Your answer
Dietary
5. Does your child have any special dietary restrictions? If yes, please list and outline potential reactions.
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Your answer
Swimming Ability
6. Choose one of the following for your child's swimming ability
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Proficient
Non-proficient
Non-participant
7. Is there any other information that would be useful for the school to know?
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Your answer
8. In the event of an emergency, and should parental contact be unsuccessful, the school is authorised to obtain medical attention for my child.
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Yes
No
Consent
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