Medical And Consent Form - Child
Download a blank fillable Medical And Consent Form - Child in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Medical And Consent Form - Child with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2Medical and consent form – Child
Complete form in BLOCK LETTERS
Participant details
First name
Last name
Date of birth
n
Male
/
/
n
Female
School name
Year group
Postal address
Postcode
Program details
Program number (if known)
Centre name
Date from
Date to
/
/
/
/
Parent/guardian contact details
First name
Last name
Postal address
Postcode
Home phone
Email
Mobile phone
Work phone
Fax number
n
n
n
n
Relationship to participant
Parent
Guardian
Grandparent
Family member
Allergies and special diets
Sport and Recreation endeavours to provide safe, healthy meals to all clients, including those with special dietary needs. Those at risk from food
related anaphylaxis require the highest level of care. It is important that we receive information regarding food related allergies even if your child
is attending a self-catered program. This form MUST be received by Sport and Recreation at least two weeks before the program commences.
If your child has a special dietary need please provide information using the categories below.
n
1. Food related anaphylaxis diagnosed by a doctor. (An anaphylaxis action plan and at least one adrenaline auto-injector MUST be provided).
Please indicate the item/s your child CANNOT eat
Peanuts
Tree nuts
Egg
Wheat
Sesame
Crustaceans
Fish
Milk
Soy
Sulphites (specify below)
Other/further information
n
2. Allergy or intolerance. (Particular foods can cause discomfort and illness, but are not life threatening).
Please indicate the item/s below your child CANNOT eat
Peanuts
Tree nuts
Egg
Wheat
Sesame
Crustaceans
Fish
Milk
Soy
Gluten
Lactose/Dairy
Yeast
Food Additives (specify below)
Sulphites (specify below)
Other/further information
n
3. Aversion/religious beliefs/lifestyle choice. (You or your child have made a decision not to eat these foods, or to eat certain types of foods).
Please indicate your child’s special diet
Vegan
Vegetarian
No red meat
No beef
Halal
Kosher
Other/further information
n
4. Non-food related allergy. (A doctor has diagnosed my child with a non-food related allergy).
Please indicate your child’s non-food related allergy
Insect bite/sting (specify below)
Medication (specify below)
Other (specify below)
Other/further information
n
n
Has he/she been hospitalised with a severe allergic reaction
Yes
No
n
n
Has he/she been prescribed an adrenaline auto injector (EpiPen® or AnaPen®)
Yes
No
n
n
Does he/she have an ASCIA Action Plan for anaphylaxis
Yes
No
Children diagnosed with anaphylaxis must have an ASCIA Action Plan and at least one auto-injector.
(Please attach and return with the form).
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal