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2018 Year 09 Aquatics Medical Form


required = required

Student Details

Medical Conditions

Please indicate


If you answered 'YES' please give details of the medical/health problem.

Medication



If you answered 'Yes' please give details of medication, providing name, reason, dosage and any side effects.
**NOTE: Any medication for occasional or regular use will be the responsibility of the student to carry. He/She must inform staff of the above information in case their assistance is needed.

Please indicate any illness, injury, allergy or disability which may effect your child's participation in any activity







Special Dietary Requirements








Parent or Guardian Details

Emergency Contact Details

If parent/caregiver unable to be contacted

Family Doctor / Medical Clinic

(If relevant)

Medicare/Health/Ambulance Fund



Other relevant information

Please provide any other relevant information

Consent and Authorisation

I submit student health information and include all details of health/medical information and any limitations for the activity concerned. I will forward any updated information if health/medical status changes prior to the camp.
I agree to delegate my authority to staff involved who may take whatever action they deem necessary to ensure the safety, well being and successful conduct of the students as a group, or individually on the camp.
I authorise the staff to obtain medical assistance, which they deem necessary should an accident or illness occur and agree to pay all medical, dental and evacuation expenses incurred on behalf of the above student.
I further legally authorise qualified medical practitioners to administer an anaesthetic ot to carry out necessary surgical procedures if such an eventuality arises.
I give my consent for the above student's local doctor or medical specialist to be contacted in an emergency.

Parent and Student Agreement



Name
Date
Name
Date

Please ensure you click on "SUBMIT"

'Student Rules for Travel Groups Camps & Tours (Overnight Stays)'

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