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Medical consent form

 

​The Department of Education and Training through Ashmore State School is collecting personal information in accordance with Education (General Provisions) Act 2006 in order to maintain student medical consent records. The information will only be accessed by Department of Education and Training. The information will not be given to any other person or agency unless consent is provided.

  • Class
  • Date of birth
  • Gender
  • Given name
  • Surname
  • Home address
  • Postcode
  • Home phone number
  • Work/Mobile phone number
  • Details of medical cover (MBF etc)
  • Pension concession details
  • Expiry date
  • Medicare card number
  • Number of person on card
  • Medicare expiry date
  • Please tick if any of the following medical conditions apply to your child:
    If you ticked any of the above conditions, you MUST complete the additional information sheet.
  • Phobias
    If yes, please provide details.
  • Medical allergies (e.g. penicillin, analgesics)
    If yes, please provide details.
  • Food allergies (medically diagnosed e.g. coeliac, dairy etc.)
    If yes, please provide details.
  • Special dietary requirements (religious reasons, vegetarian, no pork etc.)
    If yes, please provide details.
  • Heart conditions / recent operations or injuries
    If yes, please provide details.
  • Asthma / Other respiratory problems
    If yes, please provide details.
  • Sinus and/or hayfever
    If yes, please provide details.
  • Sleepwalking
    If yes, please provide details.
  • Bedwetting
    If yes, please provide details.
  • Has your child had an infectious disease recently?
    If yes, please provide details.
  • Is your child immunised for measles, chicken pox etc.?
  • Tetanus booster
    If your child has received a tetanus booster, please enter the year last given.
  • Other relevant information
  • Administering medication
    I understand that school staff can not administer over the counter medication, including analgesics, homeopathic or prescribed medication unless they meet the accountability of a written request from a parent / guardian accompanied by written advice from a medical practitioner and with the medication in the original labelled container.
  • Authorisation for qualified practitioners, if required, to administer:
    Please tick to authorise the above.
  • Is your child arriving early or late from camp?
    Please give details including approximate timeframes.
  • Additional details or conditions
    If your child has any other additional details or conditions please outline.
  • Custodial issues
    Are there any custodial issues that the Principal and/or staff of Runaway Bay Sport and Leadership centre should be made aware of? If yes, please outline.
  • Medical practice
  • General practitioner's name
  • Medical practice phone number
  • Secondary emergency contact
  • Relationship to child
    E.g. aunty / grandparent etc.
  • Phone number
  • Authorisation to obtain medical attention
    I hereby authorise the Principal, or his/her representatives, to obtain such medical attention as may be deemed necessary, and I understand the costs will be passed onto my child's school. I am responsible for reimbursing the school.
  • Agreement
    By ticking this button, I agree that all details above are true and correct.
  • Date
    Select a date from the calendar.
  • Consent to use photographs
    In the past photographs have been taken of students for school publications (e.g. Prospectus, handbooks, website) and occasional newspaper and television stories. Please indicate your willingness to allow your child's photograph to be taken for the purposes outlined.