Primary School Nursing Program Student Referral Form Page 3
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4Section C
PARENT Consent
To be completed by Parent/Guardian
If you require assistance to complete this form please speak to your child’s teacher.
To provide consent to the health assessment and to the school receiving a written report of the assessment, please tick
the Yes boxes:
Yes
No
I consent to the School Nurse conducting a health assessment of my child and understand that the
nurse will provide me with a written report.
Yes
No
I consent to the nurse providing my child’s teacher/principal with a written report regarding the
outcome of the assessment and classroom management advice where appropriate.
Child’s Name
Child’s Date of Birth
/
/
Male / Female / Indeterminate / Intersex / Unspecified (Please circle)
Year Level
Room No.
Signature
Parent/Guardian
Name (please print)
Date
/
/
Parent/Guardian
Section D
Your Child’s Personal Details
To be completed by Parent/Guardian
Parent/Guardian 1 Name
Is this the mother, father or other?
Mother
Father
Other (please specify)
Tel No (H)
(W)
(M)
Parent/Guardian 2 Name
Is this the mother, father or other?
Mother
Father
Other (please specify)
Tel No (H)
(W)
(M)
Child’s Address
Postcode
Language Spoken at Home
Child’s Country of Birth
Non-Aboriginal / Aboriginal / Torres Strait Islander / Both Aboriginal and Torres Strait Islander (Please Circle)
Current School
Previous School attended by your child (if relevant)
Does your child have a medical condition, developmental concern, or a learning problem?
Yes
No
For example asthma, diabetes, epilepsy, cerebral palsy.
If YES, please specify
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