MATTHEW FLINDERS GIRLS SECONDARY COLLEGE

CONFIDENTIAL MEDICAL INFORMATION FOR SCHOOL COUNCIL APPROVED SCHOOL EXCURSIONS AND CAMPS
(Please complete and return as soon as possible)
The school will use this information if your child is involved in a medical emergency. All information is held in confidence. This medical form must be current when the excursion/program is run. Parents are responsible for all medical costs if a student is injured on a school approved excursion unless the Department of Education and Early hildhood Development is found liable !liability is not automatic". Parents can purchase student accident insurance cover from a commercial insurer if they wish to or through #$A $nderwriting Agency !ph% &&'& ()*'".

STUDENT NAME: DATE OF BIRTH: PARENTS/GUARDIANS FULL NAME: ADDRESS: POSTCODE: EMERGENCY TELEPHONE: AFTER HOURS: BUSINESS HOURS: SCHOOL YEAR:

NAME AND ADDRESS OF FAMILY DOCTOR:

MEDICARE NUMBER: MEDICAL INSURANCE FUND: AMBULANCE SUBSCRIBER? MEMBER NUMBER:

,E-

+ ./

IF YES, AMBULANCE NUMBER :

PLEASE TICK IF YOUR CHILD SUFFERS ANY OF THE FOLLOWING:

+ + +

0ed 1etting Diabetes 0lac5outs

+ + +

2its of any type Di44y -pells 7igraine

+ + +

3eart ondition -leep 1al5ing Travel -ic5ness

Asthma
!6f tic5ed complete Asthma 7anagement Plan"

/ther%

ALLERGIES TO:

+ + +

7edication% 2ood% /ther%

CARE IS RECOMMENDED FOR THESE ALLERGIES?

WHAT SPECIAL

YEAR

OF LAST

TETANUS IMMUNISATION:

Tetanus 6mmunisation is normally given at five years of age !as Triple Antigen or DT" and at fifteen years of age !ADT".
/var/www/apps/conversion/tmp/scratch_2/208437691.doc

IS YOUR CHILD PRESENTLY TAKING TABLETS AND/OR MEDICINE? IF YES, PROVIDE THE NAME OF MEDICATION, DOSE AND TAKEN:

+ ,E-

+ ./

WHEN AND HOW IT IS TO BE

All medication must be handed to the teacher in charge prior to leaving. All containers must be labelled with your child8s name9 the dose to be ta5en as well as when and how it should be ta5en. The medications will be 5ept by the staff and distributed as re:uired. 6nform the teacher;in;charge if it is necessary or appropriate for your child to carry their medication !for example9 asthma puffers or insulin for diabetes". A child can only carry medication with the 5nowledge and approval of both the teacher;in;charge and yourself. IS THIS THE FIRST TIME YOUR CHILD HAS BEEN AWAY HOME? CONSENT TO MEDICAL ATTENTION 1here the teacher in charge of the excursion is unable to contact me9 or it is otherwise impracticable to contact me9 6 authorise the teacher in charge to% onsent to my child receiving such medical or surgical attention as may be deemed necessary by a medical practitioner Administer such first aid as the teacher in charge may judge to be reasonably necessary

FROM

+ ,E-

+ ./

SIGNATURE OF PARENT/GUARDIAN: RELATIONSHIP

TO

DATE:

STUDENT:
PHONE/MOBILE NUMBER DURING THIS CAMP:

EMERGENCY CONTACT

The Department of Education and Early hildhood Development re:uires this consent to be signed for all students attending school excursions that are approved by the -chool ouncil. Not : ,ou should receive detailed information about the excursion/program prior to your child8s participation and a Parent onsent 2orm. 6f you have further :uestions9 contact the school before the program starts.

/var/www/apps/conversion/tmp/scratch_2/208437691.doc