NORTH MELBOURNE PRIMARY SCHOOL

CONFIDENTIAL MEDICAL INFORMATION GRADE 3 FOREST EDGE CAMP 2016

Please complete and return by Friday, 22ND APRIL at the latest. This report is intended to assist the school in the case of any medical emergency with your child. All information is held in confidence, and these forms will be destroyed after the camp or excursion.

Please give your attention to all sections marked with the symbol, ►this will ensure we have sufficient information regarding your child.

CAMP: Grade 4 CampLOCATION: Anglesea YMCA Recreation camp DATE: 25th – 27th May 2016

► Child’s Name …………………………………………………... Date of Birth ……………….………. Grade ………………..

► Parents/Guardian’s Information

Mother

/

Father

Name

Home Address

AH/Home Phone Number

BH/Work Phone Number

Mobile Phone Number

►Emergency Telephone (In case Parents/Guardians not available)

Emergency Contact’s Name …………………………………………

A/H Phone No:…………………………….. B/H Phone No: ………………………………… Mobile Phone No: ……………………………..

►Name of Family Doctor …………………………………………………..

Doctor’s Address …………………………………………………………..….

Medicare No:………………………………. Ambulance Fund Membership: Yes/No Member Number: ………………….. Expiry Date:……

Medical Hospital Insurance Fund: ……………………………………………. Number:………….…………..

►Tetanus Immunisation: The last tetanus immunisation was given on ………………………………….

If over 10 years since last immunisation, please tick if a booster is to be arranged by parents before the camp.

Booster Date ………………….

► Please tick if your child suffers from any of the following:

Asthma / Headache/Migraine / Travel Sickness / Epilepsy
Heart Condition / Diabetes / Dizzy Spells / Blackouts
Sleepwalking / Bedwetting / Severe reaction to beestings / Anaphylaxis
Fits of any type / Other (please give details)

► Please tick if your child suffers from any allergies

Penicillin / Other Drugs / Any Foods / Other
Please give details of allergies
What special care is recommended?

►Previous Experience

Is this the first time your child has been away from home? Yes/No Is your child able to sleep on a top bunk bed? Yes/No

►Bike riding Ability (Please tick the boxes that describe your child best)

☐Cannot ride (never ridden) ☐Not confident☐Rides regularly☐Confident rider

►Swimming Ability (Please tick the distance your child can swim comfortably)

☐Cannot Swim (0m)☐Weak Swimmer (<50m)☐Fair Swimmer (50-100m)☐Competent Swimmer (100-200m) ☐Strong (200+)

►Special Diet – Does your child require a special diet? Yes/No

Vegetarian / Halal / Other- please give details

OTHER MEDICAL REQUIREMENTS

Please attach a note if there is insufficient space.

All medicines must be handed to the teacher in charge prior to leaving. All containers must be labelled with your child’s name, the dose to be taken as well as when and how it should be taken The medications will be kept by the staff and distributed as required. Inform the teacher in charge if it is necessary or appropriate for your child to carry medication (eg: asthma puffers or insulin for diabetes). A child can only carry medication with the knowledge and approval of both the teacher in charge and yourself. Please do not allow your child to be in possession of any other medicine whilst on the camp.

►Tablets and Medicines / Is your child currently taking tablets/medicine? Yes/No

►If YESplease indicate the details in below.

Medication ………………………………………………………………………………………………..

Reason/Indication it is required …………………………………………………………………………..

Dosage, Frequency and Administration……………………………………………………………………………………

►Medication will be applied if water, quiet time, bandaid or other similar attention is not effective within a short time. Should there be a medical matter which is more serious than ‘mild discomfort’, or your child does not improve when the medication is administered, the teachers will contact parents immediately.

I authorise the teacher in charge to administer, in the prescribed doses for my child,

❏Panadol / similar liquid

❏Allergy relief medication

Permission for PG dvd

You can be assured that staff will carefully monitor what your child views at camp, but some worthy DVDs have a “PG” rating. Should teachers select a “PG” rated DVD for a camp movie night, we would appreciate your approval to allow your child to watch it

❏I hereby grant permission for my child to watch a PG dvd whilst on camp.

ASTHMA RECORD

►My child suffers from mild/occasional asthma, and requires medication only if needed at these times. Yes/No

►My child requires asthma medication on a regular basis. Yes/No

► If you have answered YES to either of the above, Please complete and return the ASTHMA MANAGEMENT FORM.

The Department of Education requires this consent form to be signed for all students who attend government school excursions that are approved by the school council.

Parents are responsible for all medical costs if a student is injured on a school approved excursion unless the Department of Education is found liable (liability is not automatic). Parents can purchase student accident insurance cover from a commercial insurer if they wish to.

Medical Consent

Where the teacher in charge of the excursion is unable to contact me, or it is otherwise impracticable to contact me, I authorise the teacher in charge to:

-Consent to my child receiving any medical or surgical attention deemed necessary by a medical practitioner.

-Administer such first aid as the teacher in charge judges to be reasonably necessary.

-Call an ambulance if required, regardless of ambulance cover.

► Signature of Parent/Guardian …………………………….….… Name ………………………………………….Date ……………….