Student Health Form

Please complete this form.

In accordance with the Department of Education’s policy, we are required to obtain the following information for each student participating in excursions. We are required to update our records each excursion as details may change.

First Name *

Last Name *

Date of Birth *

Year Level *

Room Number *

Parent/Guardian Name *

Address: *

Medicare Number *

Medicare Individual Reference Number

Preferred contact number: *

Alternate contact number:

Email Address

Emergency Contact Details: (other than parent) *

Contact Number *

Name of Family Doctor *

Contact Number

Medical Details

Is your child subject to seizures, fainting, epilepsy, diabetes or any other condition that may affect his/her safety during an excursion? *YesNo

If “yes”, please give details

Allergies

Is your child allergic to any of the following?

(Please give details or leave blank)

Has your child had a Tetanus vaccination? *YesNoDon't know!

If yes, enter the year of last tetanus vaccination

Medication

Parents /carers are requested to make arrangements with the teacher-in-charge for the safekeeping and handling of medications prior to any excursion.

Is your child presently taking tablets and/or other forms of medication? *YesNo

If "yes", state name of medication, dosage and frequency of use

Please provide, in the space below, any other information about your child (i.e. ADHD, ASD, ANXIETY etc) that will enable us to provide better care for your child

Signed by: *

Date