HEALTH FORM NAME:
DATE OF BIRTH:
COMMENCEMENT YEAR/TERM:
YEAR GROUP:
SECTION 1: CONTACTS PRIMARY EMERGENCY CONTACT Name: …………………………………………… Relationship: …………………………………………… Phone: …………………………………………………………………………………………………………… Email: …………………………………………………………………………………………………………….. SECONDARY EMERGENCY CONTACT Name: …………………………………………… Relationship: …………………………………………… Phone: …………………………………………………………………………………………………………… Email: …………………………………………………………………………………………………………….. GENERAL PRACTITIONER Name: …………………………………………… Phone: ………………………………………………….. Address: ………………………………………………………………………………………………………… MEDICARE NUMBER ……………………………………………………………………………………………………………………… PRIVATE HEALTH FUND (international applicants without a Medicare number should adopt private health insurance) Name of fund: ………………………………………………………………………………………………….. Membership Number: …………………………………………………………………………………………
SECTION 2: IMMUNISATIONS [ ] My child is fully immunised and I have attached a current immunisation certificate. [ ] My child is not immunised and I accept that if there is an outbreak, my child will be excluded from school.