MEDICAL FORM

Personal Details

Child's Full Name*

Date of Birth*

Please indicate if your Child has suffered from any of the following:

Allergies
Asthma or Respiratory Problems
Heart Condition
Sight or hearing disorder
Fears/Phobias
Bedwetting
Headaches
Nosebleeds
Diabetes
Epilepsy
Bleeding Disorder
Back, bone or joint problems
Recent illness, injury or surgery
ADHD/ADD - please provide known behaviour and management strategies below
Aspergers - please provide known behaviour and management strategies below

Further Details or Other Conditions

Medications Required

Please note: Medication is kept in safe keeping and is administered under the management of a Kiah Park supervisor.

Drug Reactions

Special Dietary Needs

Pain Relief
Please label provided pain medication with your child’s name; this will be held in safe keeping at Kiah Park and returned to your child at the end of camp. Pain medication will be administered and noted by a Kiah Park Supervisor.

In case of an emergency I grant the person in charge at Kiah Park authority to seek any necessary medical assistance for my child. I give permission for camp staff to administer the supplied emergency medication if my child is unable to self-administer supplied medication. I declare that the information provided on this form is complete and correct.

Parent Name*

Contact Phone Number*

Email Address*

Allergy Management Plan

Please complete the following section.

Does the participant generally suffer a systemic/anaphylactic reaction to the allergen?*

YesNo

Is there a family history of anaphylaxis?*

YesNo

Has the participant been admitted to hospital for an allergic reaction?*

YesNo

Does the participant take adrenaline (Epi-pen) when suffering from an allergic reaction?*

YesNo

Allergy

Please specify all levels of allergic reaction the participant has suffered in the past:

Localized (any rash/itching/swelling at the site of the allergen)
Systemic (any rash/itching/swelling away from the site of the allergen)
Anaphylactic (severe breathing problems, swelling of body, emergency situation)

List of medication used to prevent allergic reaction, including dosage:

List medication or treatment used if allergic reaction occurs, including dosage:

Asthma Management Plan

Please only complete the following section if your child has Asthma.

Regular Medication & Dosage

Additional Medication in case of attack (include dosage)

List of known trigger factors