Online Medical Form » Camp Laurence

School

School Name*

Student Details

First Name*

Last Name*

Date of Birth*

Sex*

Male
Female
Other

Address*

Suburb*

Emergency contact

Name*

Phone (Home)*

Phone (work)*

Phone (mobile)*

Medical Cover

Medicare Number*

Ambulance Cover*

Yes
No

Private Medical Cover*

Yes
No

Membership Number

Doctor's Name*

Doctor's Phone Number*

Medical Conditions

Does your child suffer from any chronic injury or illness?*

Yes
No

Please give details

Does your child suffer from asthma?*

Yes
No

Please give details

Does your child suffer from Heart Problems?*

Yes
No

Please give details

Does your child suffer from Blood Pressure problems?*

Yes
No

Please give details

Does your child have any emotional / behavioural disorders?*

Yes
No

Please give details

Does your child have any phobias?*

Yes
No

Please give details

Does your child require medication?*

Yes
No

Please give details

May we administer paracetamol if required?*

Yes
No

Has your child been ill or required medical attention in the last 4 weeks?*

Yes
No

Please give details

Please attach a medical certificate

If your child has seen a doctor in the last four weeks please attach a medical certificate consenting to their attendance

Date of last tetanus injection

If your child's tetanus is not current please see your doctor

Does your child wet the bed?*

Yes
No

Does your child sleepwalk?*

Yes
No

Does your child suffer travel sickness?*

Yes
No

Dietary Requirements

Does your child have any special dietary requirements?

Vegetarian
Vegan
Coeliac / Gluten Intolerance
Nut Allergy
Dairy Intolerance
Halal
Kosher
Other

If Other, please give details

Activities

How would you rate your child's swimming ability?*

Unable
Poor - Basic strokes, only limited strokes beyond domestic swimming pool
Good - Strong swimmer, able to swim confidently in a variety of water conditions
Excellent - Very strong and confident, could swim 50 metres fully clothed

Please state any activity restrictions for your child

Parent or guardian consent*

As parent/guardian I understand that Camp Laurence and its instructors will take reasonable care for the welfare and safety of those attending the camp but are not responsible for any accident or sickness otherwise occurring. I acknowledge that going on camp may involve my child participating in activities of a hazardous nature, though Camp Laurence and its instructors will take reasonable care to minimise risk to participants I have detailed herein and on any attached pages any disabilities or susceptibilities affecting my child, that may place him/her at greater than normal risk. I authorise Camp Laurence and its instructors to obtain medical assistance and/or ambulance transportation in the event of illness or injury as they think necessary. I acknowledge that I am able to obtain private insurance cover for my child in respect of any accidents or sickness at the camp. Should my child need to be returned home for any reason I will cover any associated costs. I consent to my child attending camp on this understanding

I have read and accept the statement above

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