Medical Information Form

Your Name*

Student Name*

Relationship to Student*

Address*

Street Address Suburb Post Code

Email*

Telephone Home*

Telephone Mobile*

Telephone Work*

MEDICAL INFORMATION

Medical Centre

Doctors Name

Doctors Telephone

Private Medical Insurance Company

Policy Number

Medicare Policy Number

HEALTH INFORMATION

Does your child suffer from any allergy or health condition*

Yes
No

If your answer is yes please give full details below

Symptoms following exposure

General precautions to prevent an emergency

REQUIRED TREATMENT & MEDICATION

1. Does your child require immediate medication

( if so please provide medication to be left with staff in the case it is required to be administered)

2. Can your child self administer medication

3. If your answer to question 2 is no do you give the Principal or a staff member permission to administer medication that you have provided

Please give details of required medication & treatment

I

authorize for a ambulance to be called in the case of an emergency, all medical and surgical treatment, X-ray, laboratory, anesthesia, and other medical and/or hospital procedures as may be performed or prescribed by the attending physician and/or paramedics for my child and waive my right to informed consent of treatment. This waiver applies only in the event that neither parent/guardian can be reached in the case of an emergency.

Child Photo

For life threatening allergies or health conditions where immediate treatment or medication is required to be administered a current photo of the child is required.

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Medical Information Form

MEDICAL INFORMATION

HEALTH INFORMATION

REQUIRED TREATMENT & MEDICATION

ACCOUNTS IMPORTANT ANNOUNCEMENT

Enrolment

Medical Information Form

MEDICAL INFORMATION

HEALTH INFORMATION

REQUIRED TREATMENT & MEDICATION

ACCOUNTS IMPORTANT ANNOUNCEMENT

Enrolment

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