2019 Camp Dunedin - Child Health Form
Please complete a separate form for every child attending camp. The information on this form will be shared with all LAs attending camp. It will be used to ensure the health needs of your child will be met and in a case of emergency.Feel free to also discuss health needs/concerns with any of the LAs attending camp.
Name of child
Please tick if the student experiences any of the following: *
Is the child currently taking any medication? *
If you answered 'yes' to medication, please specify the name of medication, the dosage and the time to be taken and the adult responsible for administering this medication :
Has the child had any major injuries (breaks or strains) or illness (glandular fever etc) that could effect their ability to participate in activities? *
If you answered 'yes' to injuries or illness please explain below:
Is the child allergic to any of the following? *
If you answered 'yes' to allergies, please specify the allergy and the treatment required as well as who has this treatment onsite: i.e Bob is allergic to bees and I have his epi pen on me at all times.
Is the child's tetanus up to date? *
Please outline any dietary requirements: *
Can we give pain/flu medication if necessary? *
To the best of your knowledge, has the child been in contact with any contagious/infectious diseases in the past four weeks? If 'yes' please explain: *
Is there any other information the staff should know to ensure the physical and emotional safety of the child? (e.g. cultural practices, anxieties, phobias) *
Medic Alert Number (if applicable):
Please tick that you agree to these conditions (by agreeing to them you are "signing" this form): *
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