Medical & Custodyform

MEDICAL & CUSTODYFORM

Medical Information:

1. Doesyour child/ren have any disabilities or medical conditions we should be aware of? YES NO

Child Name:______Condition/s:______

Care plan/s______

______

Child Name:______Condition/s:______

Care plan/s______

______

Child Name:______Condition/s:______

Care plan/s______

______

2. Does your child/ren have asthma?YESNO

Child Name:______Care plan/s : ______

PLEASE TURN OVER PAGE

3. Does your child/ren have any allergies? YESNO

Child Name:______Allergies:______

Care plan/s______

Child Name:______Allergies:______

Care plan/s______

Child Name:______Allergies:______

Care plan/s______

4. Does your child/ren have any fears or phobias we need to be aware of?YESNO

Child Name:______Fears:______

Management:______

______

Child Name:______Fears:______

Management:______

______

Child Name:______Fears:______

Management:______

______

5. Does your child/ren have behavioural or issues with safety towards themselves or other people that would be helpful to be aware of for example: running away, aggression, swallowing objects? YES NO

Child Name:______Behaviour/s:______

Management:______

Child Name:______Behaviour/s:______

Management:______

5. Does your child/ren have behavioural or issues with safety towards themselves or others?

Child Name:______Behaviour/s:______

Management:______

6. Are there custody issues that Northreach Kidsz need to be aware of?YESNO

Please provide specific details and outline concerns: ______

______

Provide any other information you would like to provide in relation to your child/ren’s involvement with Northreach Kidz.here:______

______

In the event of serious injury or where the leaders believe that the child/ren requires immediate medical attention, an ambulance will be requested.

I/We ______, being the parent or legal guardian consent to the said child/ren participating in activities and related trips of the Northreach Baptist Kidsz Program. I/We release all persons acting as leaders from any liability whatsoever resulting from personal injury to the said child/ren.

Although all care will be taken, the Northreach Kidsz team of leaders accepts no responsibility for any accident or injury that may occur. In the event of an accident, injury or illness, first aid will be administered and ambulance called if deemed necessary. The parent will be responsible for all costs associated with ambulance transport and hospital cover.

Parent/s Signature:______

Print Parent/s Name:______

Date:_____ /______/ 2015

Thank you for completing this form,

From Northreach Kidz Team