Medical and Consent Form - Child
Medical and consent form – Child
Participant details
First name
School name
Postal address
Postcode
Last name
Year group
Parent/guardian contact details
First name
Home phone
Email
Mobile phone Work phone Fax number
Relationship to participant
n
Parent
n
Guardian
n
Grandparent
n
Family member
Postal address
Postcode
Last name
Date of birth
/ /
Program details
Program number (if known) Centre name
Date to
/ /
Date from
/ /
n
Male
n
Female
Allergies and special diets
Sport and Recreation endeavours to provide safe, healthy meals to all clients, including those with special dietary needs. Those at risk from food
related anaphylaxis require the highest level of care. It is important that we receive information regarding food related allergies even if your child
is attending a self-catered program. This form MUST be received by Sport and Recreation at least two weeks before the program commences.
If your child has a special dietary need please provide information using the categories below.
n
1. Food related anaphylaxis diagnosed by a doctor. (An anaphylaxis action plan and at least one adrenaline auto-injector MUST be provided).
Please indicate the item/s your child CANNOT eat
Peanuts
Tree nuts
Egg
Wheat
Sesame
Crustaceans
Fish
Milk
Soy
Sulphites (specify below)
Other/further information
n
2. Allergy or intolerance. (Particular foods can cause discomfort and illness, but are not life threatening).
Please indicate the item/s below your child CANNOT eat
Peanuts
Tree nuts
Egg
Wheat
Sesame
Crustaceans
Fish
Milk
Soy
Gluten
Lactose/Dairy
Yeast
Food Additives (specify below)
Sulphites (specify below)
Other/further information
n
3. Aversion/religious beliefs/lifestyle choice. (You or your child have made a decision not to eat these foods, or to eat certain types of foods).
Please indicate your child’s special diet
Vegan
Vegetarian
No red meat
No beef
Halal
Kosher
Other/further information
n
4. Non-food related allergy. (A doctor has diagnosed my child with a non-food related allergy).
Please indicate your child’s non-food related allergy
Insect bite/sting (specify below)
Medication (specify below)
Other (specify below)
Other/further information
Has he/she been hospitalised with a severe allergic reaction
n
Yes
n
No
Has he/she been prescribed an adrenaline auto injector (EpiPen® or AnaPen®)
n
Yes
n
No
Does he/she have an ASCIA Action Plan for anaphylaxis
n
Yes
n
No
Children diagnosed with anaphylaxis must have an ASCIA Action Plan and at least one auto-injector.
(Please attach and return with the form).
Complete form in BLOCK LETTERS
Page 1/2
Free Download
Medical and Consent Form - Child PDF
Favor this template? Just fancy it by voting!
(0 Votes)
0.0
Related Forms
