2018 - Snow Trip Medical Form
Please fill in all fields with appropriate information
Email address *
Student's First Name *
Student's Surname *
Student's Mobile Number *
Address *
Home Phone
Work Phone
Parent Guardian Name 1 *
Parent Guardian Name 2 *
Parent Guardian Mobile 1 *
Parent Guardian Mobile 2 *
Medicare Number *
Medicare Expiry Date *
Private Health Fund Name
Private Health Fund Number
Is your child in good health? *
Does your child suffer from any allergies, illness or injuries (including anaphylaxis)? *
If 'yes' please provide details
Does your child require any regular medication? *
If 'yes' please provide details (inc. dosage)
Has your child suffered from any acute illness in the past four months? *
If 'yes' please provide details
Has your child been treated by a doctor in the past four weeks? *
If 'yes' please provide details
Has your child had any major surgery? *
If 'yes' please provide details
Has your child had the Diphtheria Tetanus Toxoid Booster injection? *
Does your child wet the bed? *
Does your child sleepwalk *
Does your child have any special dietary requirements? *
Please provide details of any dietary requirements
Do you give permission for Panadol to be administered, if required? *
Please indicate the number of times your son/daughter has been skiing/ snowboarding in the past: *
I/We give permission for my child to swim in the hotel pool, spa and sauna. I understand that a CTHS staff member will be supervising. *
Parents/Guardian Signature *
Please type your name below
A copy of your responses will be emailed to the address you provided.
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