HEALTH FORM NAME:
DATE OF BIRTH:
COMMENCEMENT YEAR/TERM:
YEAR GROUP:
Term 1 2017
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.
SECTION 3: ALLERGIES / DIETARY REQUIREMENTS Please supply an action management plan for severe allergies. Allergic to: …………………………………………………………………………………………………… Severity: Mild intolerance / Moderate allergy / Severe allergy Onset: Ingestion / Skin contact / Inhalation / Other: ………………………………………………… Reaction: ……………………………………………………………………………………………………… Treatment: ……………………………………………………………………………………………………
N/A/ No (If an EpiPen is required, ensure that your daughter carries it at all times Epipen required: Yes and that you supply the School with an extra).
Allergic to: …………………………………………………………………………………………………… Severity: Mild intolerance / Moderate allergy / Severe allergy Onset: Ingestion / Skin contact / Inhalation / Other: ………………………………………………… Reaction: ……………………………………………………………………………………………………… Treatment: ……………………………………………………………………………………………………
N/A/ No (If an EpiPen is required, ensure that your daughter carries it at all times Epipen required: Yes and that you supply the School with an extra).
SECTION 4: HEALTH MANAGEMENT Medical condition
Yes /No
Treatment
(attach an Action Management Plan if required)
ADHD / ADD
Yes
No
Asthma
Yes
No
Diabetes
Yes
No
Hearing / Ear problems
Yes
No
Epilepsy
Yes
No
Eye / sight problems
Yes
No
Fainting
Yes
No
Heart conditions
Yes
No
Orthopaedic problems
Yes
No
Yes Yes Yes
No No No
Yes
No
Other issues eg. o o o Other
Depression / anxiety Disordered eating Self-harm
If an inhaler is required, ensure that your daughter carries it at all times.
SECTION 5– CONSENT and LEGAL MATTERS
In order to maintain proper care of your daughter, we would like to draw your attention to the regulations outlined below. The admission or retention in the School of any pupil is conditional on acceptance of these regulations. 1. In an emergency we will make every effort to contact parents or guardians, but we may not always be able immediately to do so. Therefore we ask you to give authority to the Principal / Deputy Principal / Assistant Principal Junior School to act on your behalf in an emergency. 2. Medical information outlined in this form will be shared as required with staff directly responsible for the care of your daughter. Please indicate if there is sensitive information that should only be shared with the Principal / Deputy Principal / Assistant Principal Junior School. …………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………… 3. We encourage full disclosure without which our obligation and ability to care for your child may be compromised. Please indicate if you have attached additional information: [ ] Action management plan/s [ ] Specialist medical report / information Signed: ……………………………………………………………………………………(Parent/Guardian)
Print name: ……………………………………………………… Date: …………………………………….
Please return this form and accompanying documents to: Junior School – Anita.Pipino@queenwood.nsw.edu.au Senior School – DirectorOfAdmissions@queenwood.nsw.edu.au