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2019 Dunedin Parent Health Profile
Please fill one of these forms out for each adult who is attending camp. Filling out this form means that you are authorizing this information to be shared with the LAs organizing camp to ensure we can best support you in a medical emergency.
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* Indicates required question
Adult name and age also include your child's name please. i.e Jim Maude 35 Sam
*
Your answer
Please tick if you experience 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
Are you 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: antacid
Your answer
Have you had any major injuries (breaks or strains) or illness (glandular fever etc) that could effect your ability to participate in activities?
*
Yes
No
If you answered 'yes' to injuries or illness please explain below:
Your answer
Are you 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 treatment the allergy and what the treatment is and where this can be located, i.e bee stings, my epi pen is always with me.
Your answer
Is your 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, have you 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 your physical and emotional safety ? (e.g. cultural practices, anxieties, phobias) no
*
Your answer
Medic Alert Number (if applicable): no
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 myself.
Required
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