MEDICAL FORM

    Personal Details

    Child's Full Name*

    Date of Birth*

    Please indicate if your Child has suffered from any of the following:

    Allergies
    Asthma or Respiratory Problems
    Heart Condition
    Sight or hearing disorder
    Fears/Phobias
    Bedwetting
    Headaches
    Nosebleeds
    Diabetes
    Epilepsy
    Bleeding Disorder
    Back, bone or joint problems
    Recent illness, injury or surgery
    ADHD/ADD - please provide known behaviour and management strategies below
    Aspergers - please provide known behaviour and management strategies below

    Further Details or Other Conditions

    Medications Required

    Please note: Medication is kept in safe keeping and is administered under the management of a Kiah Park supervisor.

    Drug Reactions

    Special Dietary Needs

    Pain Relief
    Please label provided pain medication with your child’s name; this will be held in safe keeping at Kiah Park and returned to your child at the end of camp. Pain medication will be administered and noted by a Kiah Park Supervisor.

    In case of an emergency I grant the person in charge at Kiah Park authority to seek any necessary medical assistance for my child. I give permission for camp staff to administer the supplied emergency medication if my child is unable to self-administer supplied medication. I declare that the information provided on this form is complete and correct.

    Parent Name*

    Contact Phone Number*

    Email Address*

    Allergy Management Plan

    Please complete the following section.

    Does the participant generally suffer a systemic/anaphylactic reaction to the allergen?*
    YesNo

    Is there a family history of anaphylaxis?*
    YesNo

    Has the participant been admitted to hospital for an allergic reaction?*
    YesNo

    Does the participant take adrenaline (Epi-pen) when suffering from an allergic reaction?*
    YesNo

    Allergy

    Please specify all levels of allergic reaction the participant has suffered in the past:
    Localized (any rash/itching/swelling at the site of the allergen)
    Systemic (any rash/itching/swelling away from the site of the allergen)
    Anaphylactic (severe breathing problems, swelling of body, emergency situation)

    List of medication used to prevent allergic reaction, including dosage:

    List medication or treatment used if allergic reaction occurs, including dosage:

    Asthma Management Plan

    Please only complete the following section if your child has Asthma.

    Regular Medication & Dosage

    Additional Medication in case of attack (include dosage)

    List of known trigger factors

    This is the beginning of your child’s adventure!