Child's Full Name*
Date of Birth*
Please indicate if your Child has suffered from any of the following:
Asthma or Respiratory Problems
Sight or hearing 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
Please note: Medication is kept in safe keeping and is administered under the management of a Kiah Park supervisor.
Special Dietary Needs
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.
Contact Phone Number*
Please complete the following section.
Does the participant generally suffer a systemic/anaphylactic reaction to the allergen?*
Is there a family history of anaphylaxis?*
Has the participant been admitted to hospital for an allergic reaction?*
Does the participant take adrenaline (Epi-pen) when suffering from an allergic reaction?*
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:
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!