Abcc Enrolment Form - 2017 Page 2
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1
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7A
/ E
:
UTHORISED NOMINEE
MERGENCY CONTACT DETAILS
Please list the details of all persons, other than parents/guardians nominated in Section 2, who are authorized to collect your child and/or can
be contacted in case of emergency. We require, at least, one emergency contact person who is able to authorize emergency medical treatment
or collect child.
Authorised Contact 3
Authorised Contact 4
Name:
Name:
Address:
Address:
Phone
Mobile:
Phone
Mobile:
Home:
Home:
Work:
Work:
Relationship to child:
Relationship to child:
Able to Collect child:
Yes
No
Able to Collect child:
Yes
No
Emergency Contact:
Yes
No
Emergency Contact:
Yes
No
H
/M
D
EALTH
EDICAL
ETAILS
D
?:
Yes
No
OES YOUR CHILD HAVE ANY MEDICAL CONDITIONS
I
,
:
F YES
PROVIDE DETAILS
D
?:
Yes
No
OES YOUR CHILD REQUIRE REGULAR MEDICATION
I
,
/
.
F STAFF WILL BE REQUIRED TO ADMINISTER MEDICATION
A SEPARATE MEDICATION AUTHORITY FORM IS TO BE COMPLETED BY THE PARENT
GUARDIAN
ALL MEDICATION IS
’
.
TO BE PROVIDED IN ORIGINAL PACKAGING WITH THE CHILD
S NAME AND DOSAGE
D
?:
Yes
No
OES YOUR CHILD HAVE ANY ALLERGIES
I
,
:
Mild
Severe
Anaphylaxis
F YES
PROVIDE DETAILS
I
A
,
/
:
Anaphylaxis Action Plan
EPI Pen
Other Medication
F
NAPHYLAXIS
DOCUMENT
MEDICATION SUPPLIED
A
P
1
CTION
LAN VALID FOR
YEAR FROM ISSUE
Expiry Date:
Expiry Date:
Name:
Expiry Date:
P
A
M
P
.
LEASE PROVIDE
LLERGY
ANAGEMENT
LAN RELATING TO YOUR CHILD
D
?:
Yes
No
OES YOUR CHILD HAVE ANY ALLERGIES
I
,
:
Mild
Severe
Anaphylaxis
F YES
PROVIDE DETAILS
A
/
:
Asthma Action Plan
Ventolin (ABCC)
Ventolin
STHMA DOCUMENT
MEDICATION SUPPLIED
A
P
1
CTION
LAN VALID FOR
YEAR FROM ISSUE
Expiry Date:
Expiry Date:
College has given permission for
child to carry and self-medicate.
P
A
M
P
.
LEASE PROVIDE
LLERGY
ANAGEMENT
LAN RELATING TO YOUR CHILD
I
MMUNIZATION INFORMATION
I
’
?
Yes
No
S YOUR CHILD
S IMMUNIZATION STATUS UP TO DATE
D
?
ATE OF LAST TETANUS INJECTION
F
.
AILURE TO MAINTAIN IMMUNIZATIONS IN LINE WITH SCHEDULE WILL AFFECT YOUR CHILD CARE BENEFIT OR CHILD CARE REBATE ELIGIBILITY
13
PCV
Yes No
Hep B
Yes
No
MenCCV
Yes
No
V
23vPPV
Hib
OPV/IPV
Yes No
Yes
No
Yes
No
DTPa
Influenza
Rotavirus
Yes No
Yes
No
Yes
No
Hep A
MMR
VZV
Yes No
Yes
No
Yes
No
2
St John’s Anglican College ABCC & St John’s EY ABCC
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