Balmacewen Intermediate School

44 Chapman Street, Dunedin, New Zealand Telephone: (03) 4 !"#$% &ac'imile: (03) 4 !"#$# (mail o))ice: o))ice*+almacewen,'chool,nName Medic Alert number (if applicable) 1. Please tick if you have any of the following Migraine "iabetes %hronic nose bleeds %olour blindness $or overnight events )leepwalking *edwetting !pilepsy #ravel sickness &eart condition (ther (please specify) Asthma $its of any type "i''y spells

+.

Are you currently taking medication, .f -!)/ please state Name of medication0s "osage and time0s to be taken (ther treatment Ailment0s

-es

No

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 Prescription medication $ood .nsect bites0stings (ther allergies 5hat treatment is re6uired,

No

Please specify

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 at my e3pense.

Print name )igned #o be read and signed by adult participant or parent0caregiver of child participant.

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