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.
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: *
Required
Are you currently taking any medication? *
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? *
If you answered 'yes' to injuries or illness please explain below:
Your answer
Are you allergic to any of the following? *
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? *
Please outline any dietary requirements: *
Required
Can we give pain/flu medication if necessary? *
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): *
Required
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