Balmacewen Intermediate School

44 Chapman Street, Dunedin, New Zealand

Telephone: (03) 4!"#$%
&ac'imile: (03) 4!"#$#
(mail o))ice: o))ice*+almacewen,'chool,n-
Name Medic Alert number
(if applicable)
1. Please tick if you have any of the following
Migraine !pilepsy Asthma
"iabetes #ravel sickness $its of any type
%hronic nose bleeds &eart condition "i''y spells
%olour blindness (ther (please specify)
$or overnight events
)leepwalking *edwetting
+. Are you currently taking medication, -es No
.f -!)/ please state Ailment0s
Name of medication0s
"osage and time0s to be taken
(ther treatment
1. &ave you had any ma2or in2uries (breaks or strains) or illness (glandular fever etc)
in the last si3 months that may limit full participation in any activities, -es
No
.f -!)/ please state the in2ury0illness.
4. Are you allergic to any of the following,
-es No Please specify
Prescription medication
$ood
.nsect bites0stings

(ther allergies
5hat treatment is re6uired,
7. 5hen was your0your child8s last tetanus in2ection,
9. (utline any dietary re6uirements.
:. 5hat pain0flu medication may your child be given if necessary,
;. #o the best of your knowledge/ have you0your child been in contact with any
contagious or infectious diseases in the last four weeks,
-es No
.f -!)/ please give brief details.
<. .s there any information the staff should know to ensure the physical and emotional
safety of you0your child, ($or e3ample cultural practices= disability= an3iety about
heights0darkness0small spaces= behaviour or emotional problems).
-es No
.f -!)/ please state or attach the information.
. also agree that if prescribed medication needs to be administered/ a designated
adult will be assigned to do this. . will ensure that prescribed medication is
clearly labelled/ securely fastened and handed to the designated adult with
instructions on its administration.
. will inform the school as soon as possible of any changes in the medical or other
circumstances between now and the commencement of the event.
. agree to my child0myself receiving any emergency medical/ dental/ or surgical
treatment/ including anaesthetic or blood transfusion/ as considered necessary by the
medical authorities present.
Any medical costs not covered by A%% or a community service card will be paid by me.
.f my child is involved in a serious disciplinary problem/ including the use of
illegal substances and0or alcohol/ or actions that threaten the safety of others/
s0he will be sent home.
Print name
)igned
#o be read and signed by adult participant or parent0caregiver of child participant.
"ate