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