Auroa Student Health profile Year 6&7 Camp 2020
y6/7 Camp health profile
Email address *
Name and year level of your child. *
Your answer
Medic alert number (if applicable)
Your answer
Community Services Card Number (if applicable)
Your answer
Please select if you have any of the following
Is the student currently taking any medication *
Required
If yes please specifiy
Your answer
Name of medication/s:
Your answer
Dosage and time/s to be taken
Your answer
Other treatment:
Your answer
Have you had any major injuries (breaks or strains) or illness (glandular fever etc) in the last six months that may limit full participation in any activities? *
Required
If YES, please state the injury/illness.
Your answer
Are you allergic to any of the following? *
Required
What treatment is required?
Your answer
Outline any dietary requirements.
Your answer
What pain/flu medication may your child be given if necessary?
Your answer
Is there any information the staff should know to ensure the physical and emotional safety of you/your child? (For example cultural practices; disability; anxiety about heights/darkness/small spaces; behaviour or emotional problems). *
Required
If YES, please state information.
Your answer
I also 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. *
Required
I will inform the school as soon as possible of any changes in the medical or other circumstances between now and the commencement of the event. *
Required
I agree to my child/myself receiving any emergency medical, dental, or surgical treatment, including anaesthetic or blood transfusion, as considered necessary by the medical authorities present. *
Required
Any medical costs not covered by ACC or a community service card will be paid by me. *
If my child is involved in a serious disciplinary problem, or actions that threaten the safety of others, they will be dealt will appropriately by staff *
A copy of your responses will be emailed to the address you provided.
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This form was created inside of Auroa School. Report Abuse