Medical and Emergency Contact Information Form

Camp Medical & Emergency Information - Confidential

The following information is required so that your child can be given the best possible care while on camp. All information is completely confidential.

Child’s Surname:		Christian Name:
Address:		Home Phone Number:
		Work Phone Number:
		Mobile Number:
Medicare Number:		Number Position on Medicare Card:
Nominated Emergency Contact Person:
Relationship to the Child:
Contact Phone Number:
Contact Mobile Number:

1.     Is your child presently taking tablets and / medication? (Please circle.)                Yes    /    No

        If yes, please state name of medication, dosage and doctor.

All medication must be handed to the teachers in charge prior to leaving for camp with your child’s name and dose to be taken.

2.     Please tick if your child suffers any of the following:

	Bed Wetting				Asthma
	Fits of any Type				Dizzy Spells
	Heart Condition				Migraine
	Black Outs				Travel Sickness
	Sleep Walking
	Other (please state).

3.     Allergies to:

	Penicillin			Foods
	Drugs			Other

4.     Is this the first time your child has been away from home? (Please circle.)          Yes    /    No

I hereby authorise medical attention to be obtained by the camp staff for my child, if, in their opinion, it is necessary. I also agree to meet the cost of such medical attention.

Parent Signature:

Date:

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