Fillable Printable Medical and Consent Form - Child
Fillable Printable Medical and Consent Form - Child
Medical and Consent Form - Child
Medical and consent form – Child
Participant details
First name
School name
Postal address
Postcode
Last name
Year group
Parent/guardian contact details
First name
Home phone
Email
Mobile phone Work phone Fax number
Relationship to participant
n
Parent
n
Guardian
n
Grandparent
n
Family member
Postal address
Postcode
Last name
Date of birth
/ /
Program details
Program number (if known) Centre name
Date to
/ /
Date from
/ /
n
Male
n
Female
Allergies and special diets
Sport and Recreation endeavours to provide safe, healthy meals to all clients, including those with special dietary needs. Those at risk from food
related anaphylaxis require the highest level of care. It is important that we receive information regarding food related allergies even if your child
is attending a self-catered program. This form MUST be received by Sport and Recreation at least two weeks before the program commences.
If your child has a special dietary need please provide information using the categories below.
n
1. Food related anaphylaxis diagnosed by a doctor. (An anaphylaxis action plan and at least one adrenaline auto-injector MUST be provided).
Please indicate the item/s your child CANNOT eat
Peanuts
Tree nuts
Egg
Wheat
Sesame
Crustaceans
Fish
Milk
Soy
Sulphites (specify below)
Other/further information
n
2. Allergy or intolerance. (Particular foods can cause discomfort and illness, but are not life threatening).
Please indicate the item/s below your child CANNOT eat
Peanuts
Tree nuts
Egg
Wheat
Sesame
Crustaceans
Fish
Milk
Soy
Gluten
Lactose/Dairy
Yeast
Food Additives (specify below)
Sulphites (specify below)
Other/further information
n
3. Aversion/religious beliefs/lifestyle choice. (You or your child have made a decision not to eat these foods, or to eat certain types of foods).
Please indicate your child’s special diet
Vegan
Vegetarian
No red meat
No beef
Halal
Kosher
Other/further information
n
4. Non-food related allergy. (A doctor has diagnosed my child with a non-food related allergy).
Please indicate your child’s non-food related allergy
Insect bite/sting (specify below)
Medication (specify below)
Other (specify below)
Other/further information
Has he/she been hospitalised with a severe allergic reaction
n
Yes
n
No
Has he/she been prescribed an adrenaline auto injector (EpiPen® or AnaPen®)
n
Yes
n
No
Does he/she have an ASCIA Action Plan for anaphylaxis
n
Yes
n
No
Children diagnosed with anaphylaxis must have an ASCIA Action Plan and at least one auto-injector.
(Please attach and return with the form).
Complete form in BLOCK LETTERS
Health details and related information
Privacy statement
The Department of Education and Communities of 6B Figtree Drive, Sydney Olympic Park, NSW 2127 will collect and store the information you voluntarily provide to
enable processing of enrolments for the program. The information will be provided to relevant staff and be provided to medical professionals where necessary. You consent
to these disclosures. If you have been asked for information regarding Aboriginal and Torres Strait Islander descent and cultural background, this information is voluntary
and is being compiled for statistical purposes only. Any information provided by you will be stored on a database that will only be accessed by authorised personnel and is
subject to privacy restrictions. The information will only be used for the purpose for which it was collected. Any information provided by you to the Department of Education
and Communities can be accessed by you during standard office hours and updated by writing to us or by contacting us on 13 13 02.
I do not wish to receive promotional information about this service offered by Sport and Recreation.
Risk warning and media consent
a) Strike out whichever does not apply:
I agree for my child/ward to attend the Centre and to undertake all activities and/or to participate in the above program. In the case of an emergency,
I authorise the Department of Education and Communities, Sport and Recreation staff, where it is impracticable to communicate with me, to arrange for my
child/ward to receive such medical or surgical treatment as may be deemed necessary. I also undertake to pay or reimburse costs which may be incurred
for medical attention, ambulance transport and drugs while my child/ward is attending the Centre/enrolled in the program.
I understand that although the Department of Education and Communities, Sport and Recreation and its service providers attempt to minimise any risk of
personal injury within practical boundaries, accidents do happen and all physical activities carry the risk of personal injury. I acknowledge that there is an
inherent risk of personal injury in physical activities that will be undertaken at the Centre/as part of the program and I accept that risk.
b) Please tick whichever applies to you
I consent / I do not consent to allow the NSW Government to use any photographs, sound and film recordings taken of my child/my ward at this
program for the promotion of NSW Government services and initiatives to the media and to the general public.
Name (print)
Signature
/ /
Date
Returning this form
Please return this form to the coordinator of your
Sport and Recreation program.
For more information call
13 13 02 or visit www.dsr.nsw.gov.au
April 2013
Does the participant suffer from the following? (Please attach details as required).
n
A current illness (e.g. flu)
n
A disability/chronic illness
n
Asthma (provide asthma plan)
n
Bed wetting
n
Attention deficit disorder (ADD/ADHD)
n
Behavioural problems
n
Diabetes
n
Epilepsy
n
Sleep walking
n
Skin condition
n
Other
Has he/she had the Combined Diptheria Tetanus Toxoid booster injection?
n
Yes
n
No Year
Has he/she been immunised against measles?
n
Yes
n
No Year
Time and dosage – please specify exact time of medication (attach details as required)
Breakfast Lunch Dinner Before bed Other
Name Time Dose Time Dose Time Dose Time Dose Time Dose
e.g. Bricanyl 8am 2 puffs 12.30pm 2 puffs 6pm 2 puffs 8pm 2 puffs
Current medication
Notes: 1. Scheduled medication must be provided in the original container (as required by legislation).
2. Staff will collect, supervise and register the taking of all medication.
3. Participants at risk of anaphylaxis need to provide at least one auto injector (e.g. EpiPens®/AnaPens®).
Medicare number
Private health insurance fund Number
Position on card
/ /
Valid till
Swimming ability
n
Strong – 50 metres unaided
n
Average – 25 metres unaided
n
Poor – 10 metres unaided
n
Non-swimmer
Optional information
Is the child of Aboriginal or Torres Strait Islander descent? (For statistical purposes only)
n
Yes
n
No
Are one/both the parents from a culturally or linguistically diverse background or community? (For statistical purposes only)
n
Yes
n
No
