Microsoft word - excur4.doc

PARENTAL PERMISSION / MEDICAL FORM FOR Bendigo/Ballart
STUDENT:

Tutor:

Parent/Guardian’s Full Name: .
Student’s Date of Birth: . Medicare Number: .
Please tick of your child suffers from any of the following:
Asthma – complete details overleaf Fits
Please specify any medical conditions, e.g. allergies or physical problems the coach needs to be aware of: . Tetanus Immunisation/Booster – Date: . MEDICINE – NAME/TYPE, DOSAGE ETC
MUST BE HANDED TO STAFF MEMBER PRIOR TO DEPARTURE
I authorise the Teacher in Charge to: 1. Administer first aid treatment as reasonably required; 2. Give consent for ambulance, dental, medical or surgical treatment as deemed necessary in the event that I am attend any excursion related to the sporting season commitment to The Peninsula School. I also undertake to inform the School of any change in my child’s medical condition during this sporting season commitment. (h:/data/admin/forms/excur4-jlm)
MANAGEMENT
Seek the advice of the asthmatic’s Doctor if necessary when completing this form
Usual maintenance medical programme followed by the asthmatic . Peak Flow Readings: Best . Critical: . (bring own peak flow meter) Medication and treatment to be used during worsening asthma: . Medication and treatment to be used during crisis situation: . QUESTIONS
i. Has the asthmatic been admitted to hospital due to asthma in the ii. Has the asthmatic been on oral cortisone for asthma within the past twelve months (eg, Prednisone, Cortisone, Betamethasone, etc)? iii. Has the asthmatic suffered sudden asthma attacks requiring  If any of the Key Questions above should be answered “YES”, then the decision for the asthmatic to attend rests entirely with the child’s Doctor.  The child’s Doctor MUST contact the Teacher in Charge of the activity,  An Action Plan for emergency treatment would also need to be provided by your Doctor. A LETTER FROM THE CHILD’S DOCTOR STATING THE DOCTOR’S DECISION
MUST ACCOMPANY THIS FORM WHEN IT IS RETURNED
2 CONDITION
SUFFERED
Usual maintenance medical programme followed by the sufferer . Medication and treatment to be used during worsening attack . Medication and treatment to be used during crisis situation . PLEASE NOTE: IF YOUR CHILD SUFFERS FROM ANY OTHER SERIOUS CONDITION, EG DIABETES,
EPILEPSY, THEN THE DECISION TO ATTEND RESTS WITH THE CHILD’S DOCTOR
Date of Birth: . Year Level: . Date Medication Commenced: . Name of Medication: . Dosage of Medication: . Time/s of day Medication is to be taken: . . Comments/Additional Information: . . I authorise staff to dispense the above medication to my son/daughter at the prescribed times. Parent/Guardian Signature: . Date: . PLEASE NOTE
The prescribed medication must be sighted by the Staff Member
in the packaging/container in which the Pharmacist has dispensed it.
Original container sighted by staff member: . Date: .

Source: http://www.tps.vic.edu.au/images/PDF/2012/T1W8/EXCUR4.pdf