PEAC Student Health & Privacy Form
Strictly Confidential
Student Details
This information, that is required for each student participating in PEAC, will allow the supervising teachers to plan and provide for your child’s individual needs while he or she attends PEAC. It is not used for any other purpose.
Is this the first time you have completed an online Medical and Consent Form for your child? *
Required
First Name *
Your child's first name
Your answer
Surname *
Your child's surname
Your answer
Date of Birth: *
MM
/
DD
/
YYYY
Gender *
School: *
Your answer
Year in 2018 *
Home Address: *
Your answer
Parent/Guardian Contact Details
Parent Name 1: *
Primary contact for PEAC
Your answer
Phone Number (mobile) *
Your answer
Phone Number (home)
If applicable
Your answer
Phone Number (work)
If applicable
Your answer
Email Address: *
This will be used for PEAC communications use only.
Your answer
Additional Parent/Guardian Contact Details
Will be used if the primary contact cannot be reached
Parent Name 2:
Your answer
Phone Number (mobile):
Your answer
Phone Number (home)
Your answer
Phone Number (work)
Your answer
Emergency Contact Details
Someone other than a parent/guardian
Name of Emergency Contact: *
Your answer
Emergency Contact Number: *
Your answer
Name of Family Doctor:
Your answer
Doctor Phone Number:
Your answer
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