JENOLAN CAVES/BATHURST EXCURSION

MEDICAL INFORMATION FORM

To be completed by the Parent/Carer and handed in a sealed envelope to your child’s class teacher.

The purpose of the questionnaire concerning your child’s medical history is to assist the teachers in the welfare of your child. All details will be treated as confidential.

EMERGENCY PHONE NUMBERS

Home Work

Answer YES or NO

  1. Is he/she in good health?
  1. Has he/she suffered any illness recently.

Specific nature………………………………………………………..

………………………………………………………………………..

  1. Has he/she been treated by a medical practitioner for an injury recently.

(If the answer is YES, please obtain a written report from the Doctor

with instructions about further treatment and a certificate stating that

the child is fit to attend the Jenolan Caves Bathurst excursion.

  1. Is he/she taking any mixture, tablets or other forms of medicine at

present? If the answer is YES please obtain full written instructions

from your Doctor. All medications are to be handed to your child’s

teacher and will be issued to your child at the correct time.

  1. Does he/she wet the bed?
  1. Has he/she been fully immunised against Tetanus? Year of injection

………………………… .

  1. Are you a current member of an Ambulance Fund?
  1. Does he/she suffer from travel sickness? (If the answer is YES and

you intend to provide medication, full written instructions and the

medication must be given to your child’s class teacher and will be

issued to your child at the correct time)

  1. Can he/she have Panadol if they are in need of it on the excursion.

What is their dosage?

Please list any other information that will assist us in caring for your child (use the back of form is necessary)

Signed Parent/Carer ……………………………………………………….Please turn over

MEDICAL INFORMATION

All information is confidential and may be returned in a sealed envelope

Student Name ………………………………………………………………..Class……….

MEDICATION

If your child is taking any medication, please complete the following:

ILLNESS………………………………………………………………………………………………..

NAME OF MEDICATION…………………………………………………………………………….

DOSAGE……………………………………………………………………………………………….

FREQUENCY OF DOSAGE…………………………………………………………………………..

All medication is to be clearly labelled and handed to a teacher.

PLEASE LIST ANY OTHER INFORMATION THAT WILL ASSIST US IN CARING FOR YOURCHILD………………………………………………………………………………………..

……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

TO ASSIST IN THE EVENT OF ILLNESS REQUIRING MEDICAL ASSISTANCE, PLEASE PROVIDE THE FOLLOWING INFORMATION:

HOME PHONE………………………………………………………………………………………...

MOBILE PHONE………………………………………………………………………………………

EMERGENCY CONTACT PHONE…………………………………………………………………..

WORK PHONE………………………………………………………………………………………..

MEDICARE NUMBER……………………………………………………………………………….

PRIVATE HEALTH FUND NUMBER……………………………………………………………….

DECLARATION: IN THE EVENT OF A MEDICAL EMERGENCY, ACCIDENT OR OCCURRENCE WHERE MEDICAL TREATMENT OF MY CHILD IS SOUGHT, I AUTHORISE, AND I AM WILLING TO ACCEPT AND PAY THE COSTS INVOLVED FOR SUCH TREATMENT. THIS INCLUDES AMBULANCE, TAXI, DOCTOR AND HOSPITAL.

SIGNED………………………………………………….

DATE…………………………………………………….