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Medical Form2018-08-01T21:54:11+00:00

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*

Only complete the appropriate Management Plans below if you have noted that your child suffers from Allergies or Asthma. Otherwise, scroll down and click SUBMIT to send your form.

Allergy Management Plan

Only complete the following section if your child has Allergies.

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)

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

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

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

Asthma Management Plan

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

PLEASE NOTE: If you would prefer to use a hard copy form, please download the Medical Form below and send via email.

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