Student Health Form
Kia Ora,

Thank you for filling out this Health Form for your child. Part of what is expected leading up to camp is the returning of vital information through forms so that every aspect of safety is accounted for.

Camp Dates:
Date: Monday 25 March - Friday 29 March (2 Camps)

Camp 1: Monday 25 - Wednesday 27 March (Pounamu Atawhai)
Camp 2: Wednesday 27 - Friday 29 March (Yr 5 Poutama)

All camp participants will spend Friday at the Lido Swimming Centre. Lunch will be provided.

Email address *
Student Name *
Your answer
Student Health Profile
Bush Camp 2019 Camp Student ID *
Health Profile Section
All health details will remain confidential to persons supervising the EOTC activities. For safety reasons, please provide information that is accurate and complete.
Name of Doctor *
Your answer
Doctor's Phone Number *
Your answer
Medic Alert Number (If Applicable)
Your answer
Medical Information
Please list all the information needed
Please tick if your child has any of the following conditions *
Medication Questions
Only answer the next set of questions if you answered YES to taking medication.

If anything changes before going on this trip please inform the classroom teacher and they will update this information.

Is your child currently taking any medication? *
What condition is the medication for?
Your answer
What is the name of the medication?
Your answer
How much do they need to take and when?
Your answer
What other treatments are they having?
Your answer
Injury/Illness and Allergy
All the following questions are compulsory.
Has your child had any major injury or illness in the last six months that could limit their participation in camp activities? *
Please give details of injury or illness
Your answer
Is your child allergic to any of the following? *
Please give details of the allergies
Your answer
What treatment is required for the allergies?
Your answer
When was your child's last tetanus injection? *
Your answer
Does your child have special dietary requirements? *
Give details of dietary requirements
Your answer
Have you been in contact with any contagious or infectious diseases in the last four months? *
Give details if answering YES to above
Your answer
Emergency Contact Information
This is vital to the communication to and from camp and in case of emergency.

Please provide details for one emergency contact. It can be the same as your child's.

Emergency Contact: Full Name *
Your answer
Emergency Contact: Day Phone *
Your answer
Emergency Contact: Cell Phone *
Your answer
Emergency Contact: Relationship to you *
Your answer
Safety Agreement Policy
Please read the following statements carefully and check the box that these are accepted to take part in Bush Camp 2019

I agree to let the school know about any changes to this information that may happen between now and the event.

I agree to receive any emergency medical, dental, or surgical treatment, including anaesthetic or blood transfusion, as considered necessary by the medical authorities present.

I agree to pay for any medical costs not covered by ACC or a community services card.

I understand that there are risks associated with EOTC events and that the school will take steps to eliminate or minimize those risks. I will do my best to follow the school’s safety procedures.

I understand that I can consult with the person in charge and withdraw my child from an activity if they feel at risk.

I understand that the school does not accept responsibility for loss or damage to personal property.

Thank You
This information is vital to the safety for all children, volunteers and staff on this trip. Do not hesitate to contact school if information needs to be updated or changed.
I have a fully functional/ waterproof tent available for use *
The tent will sleep
I acknowledge all possible precautions will be undertaken to protect the tent from damage. The school will not be liable in the unlikely event of any damage.
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