Medical Records
No medication will be dispensed to your child until this form is submitted.
Student Details
Student Name
*
First Name
Last Name
Year Level
*
Year 1
Year 2
Year 3
Year 4
Year 5
Year 6
Year 7
Year 8
Year 9
Year 10
Year 11
Year 12
Year 13
Birth Date
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Gender
*
Please Select
Male
Female
N/A
Family Doctor
*
Family Doctor Phone
*
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Parent/Guardian/Caregiver 1 Details
Parent/Guardian/Caregiver 1 Name
*
First Name
Last Name
Email
*
example@example.com
Relationship to Applicant
*
Mother
Father
Guardian
Caregiver
Other
Add Another Parent/Guardian/Caregiver
Parent/Guardian/Caregiver 2 Details
Parent/Guardian/Caregiver 2 Name
First Name
Last Name
Relationship to Applicant
Mother
Father
Guardian
Caregiver
Other
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Medical Information
Has your child suffered from:
*
Yes / No
Medication
Plan of Action
Allergies/anaphylaxis (Please specify)
No
Yes
Asthma
No
Yes
Diabetes
No
Yes
Cardiac Problems
No
Yes
Depression/Psychological issues
No
Yes
Dietary Issues e.g. coeliac, gluten free
No
Yes
Epilepsy
No
Yes
Headaches/Migraines
No
Yes
Physical Disabilities
No
Yes
Hearing e.g. hearing aid
No
Yes
Vision e.g. wears glasses/contact lenses
No
Yes
Please tick if your child has suffered from:
Allergies/anaphylaxis
Asthma
Diabetes
Cardiac Problems
Depression/Psychological issues
Dietary Issues e.g. coeliac, gluten free
Epilepsy
Headaches/Migraines
Physical Disabilities
Hearing e.g. hearing aid
Vision e.g. wears glasses/contact lenses
Other
Please specify any medication and plan of action required
*
Please list any other illnesses or conditions:
Please list any special needs your child has, particularly those relating to learning, psychological, behavioural or other conditions affecting your child's health or well being:
Please upload any documentation as appropriate for the above questions
Browse Files
Available formats: pdf, doc, docx, zip, jpg, jpeg, png, tiff
Cancel
of
I give permission for my child to be given:
*
Yes
No
Paracetamol (if clinically indicated)
Antihistamine (if clinically indicated)
Ibuprofen (if clinically indicated)
I consent to my child receiving medical treatment and over the counter medication from the school
*
yes
no
I consent to the school acting on my behalf in the event of an emergency (we will always attempt to contact parents in the event of an emergency):
*
yes
no
Please verify that you are human
*
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