HVHS Health and Consent Form
Student Name *
Your answer
Student ID Number: *
Your answer
Form Class *
Your answer
Please enter the event you are attending: *
(as per information letter)
Your answer
Emergency Contact *
Please provide TWO emergency contacts below along with a mobile number and home/work number for each
Your answer
I agree to the conditions as outlined below and give consent for my son/daughter to attend. • I agree that my son/daughter will abide by the school rules while on the trip. • I agree that my son/daughter will follow instructions given to them by the staff in charge. • I give staff the authority to arrange and/or administer, if necessary, any medical treatment for my son/daughter. *
Have you completed a Health and Consent form for 2016 already? *
If NO or your health has changed - please complete the following questions
Does your son/daughter have to take any medication?
Does your son/daughter suffer from any allergy or disability?
Has your child had an anti-tetanus injection in the last five years?
Is your child allergic to penicillin?
Has your child been in contact with an infectious disease in the last month?
If you have answered Yes to any of the above, please provide details below:
Your answer
If your son/daughter needs assistance with their medication please provide details below:
* What is the name of it? * Where is the medication stored? *What times does it need to be administered and how much?
Your answer
Details of son/daughter’s Medical Practitioner:
Please provide *Doctor's name *Contact number *Address
Your answer
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