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MEDICAL INFORMATION FORM

Please bring your child's VACCINATION RECORD to complete registration.

CHILD'S DETAILS
First Name
Middle Name
Last Name
Date of Birth
Place of Birth
Gender
MEDICAL CONDITIONS

It is important that the school be made aware of any special circumstances regarding the health of your child. To this end, please complete the following by selecting "Yes" or "No".

Does your child suffer from
Diabetes
Nut Allergies
Other Allergies
Epilepsy
Non-Epileptic Convulsions
Eyesight Difficulties
Hearing Difficulties
Take Regular Medication
Eczema
Undergone Major Surgery
Any Serious Illness
Asthma - Requires Medication
Mild Asthma
Has you child ever had any of the following diseases
German Measles (Rubella)
Measles
Mumps
Chicken Pox
Meningitis
Hepatitis
Glandular Fever
Whooping Cough
Flu
If you answered "Yes" to any of the above medical conditions, please provide further details. The School cannot accept responsibility for the consequences of withheld relevant information that would otherwise ensure your child's welfare.
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In addition to the above, are there any other details you feel we should be aware of regarding your child's health?
0 /
Has your child been inoculated against
Polio / Tetanus / Diphtheria
B.C.G. (TB)
Measles, Mumps, Rubella (MMR)
Polio
Meningitis, A, C, W135, Y
Tetanus
AUTHORISATION

Please read the following carefully before signing the authorisation below:

In an emergency, the school will take whatever action is required to safeguard your child and avoid any delay that would otherwise jeopardize their life or recovery, with the understanding that every effort will be made to contact you immediately.

However, there are numerous "non-emergencies" that occur every week, when students come to the Clinic with minor ailments. These can be treated with generally available medications.

The medications that are held by the school or their equivalent are: Paracetamol sold as Panadol or Fevadol; Ibuprofen sold as Brufen, Advil or Junifen; Strepsils which are throat lozenges; Rennies; Motillium for heartburn and stomach ache; and antihistamines for allergic reactions. 

It may be that you would not wish your child to receive these or indeed any medication at all. However if you would like your child to be able to be given any of these mild treatments, the school requires your written authorisation in the form of your signature below. 

Please note that the Medical staff will not administer medication to your child without this authorisation.  

In the event of an emergency, I have no objection to the Medical staff in the Clinic administering necessary medication to my child, or to my child being taken to a hospital for treatment, if required.

Please select one of the following options:
Parent/Guardian name:
Signature:(To be signed at our office)
Date:

Please note it is your responsibility to inform us if there is any change in your child's medical condition (i.e. newly developed allergies)

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