Medical forms

In consultation with your child’s school, Land’s Edge considers careful y the programming and locations for al Outdoor Education Programs. Your child’s safety and welfare is of utmost importance. We ask that you assist us by ensuring the fol owing matters are addressed: Medicines Details about any medications required by your child must be provided on the medical form. Al medicines are to be clearly label ed with your child’s name. If medication needs to be administrated by anyone other than your child, please provide specific instructions for administration prior to your child participating in any Land’s Edge programming. Asthma If your child suffers asthma the Asthma Management Plan must be completed prior to your child participating in Land’s Edge programming. If your child has ever been hospitalised due to an Asthma-related condition, this must be detailed on the Asthma Management Plan irrespective of the last occurrence. Allergies Details of any al ergies your child suffers must be provided on the Allergic Reaction Management Form. Medications required during the program must be provided along with details of last occurrences. Land’s Edge recommends that your child’s tetanus immunisation is up to date prior to commencement of Land’s Edge programming. Details about any fracture, dislocation or sprains that have occurred in the last three years should be provided. If necessary, Land’s Edge wil modify activities if your child is prone to fractures or has a history of recurring sprains or dislocations. Land’s Edge recommends spare sets of glasses and contact lenses for any child needing such things. Head straps for glasses are recommended as are lens cleaning kits. Please ensure your child knows how to care for contact lenses while participating in Land’s Edge programming. Keeping Dry and Warm Our recommended gear list ensures participants are adequately prepared for al weather conditions – please consider it closely and ensure a reasonable quality rain jacket or coat is provided. Some participants require joints to be strapped for sporting activities. If your child normal y requires tape, please provide sufficient tape for Land’s Edge programming and if necessary, supply non-al ergenic tape. Land’s Edge requests that mobile phones are kept at home for the duration of programming. In an emergency, Land’s Edge can be contacted at al times. Special Considerations Please contact us or your school program coordinator if there is anything further we should know about your child. Confidentiality is assured. In the event of your child being unable to complete Land’s Edge programming, a pickup wil be required either by the school or parents. Directions wil be provided by Land’s Edge staff through the office. Thank you for your time completing these forms. Land’s Edge looks forward to providing a safe and enjoyable Outdoor Education experience. Information provided on this medical form is confidential. It wil not be reused, rented, loaned, sold or otherwise disclosed to a third party except with prior written permission. Information provided wil not be used to restrict activities rather it enables Land’s Edge to adequately prepare al programming. STUDENT DETAILS: Name: ________________________________________________________ D.O.B: ____________________ Address: __________________________________________________________________________ Male ⎕ Female ⎕ Please tick Medicare No: ___________________________ Private Health Insurance: _____________________ No: ______________________ Please circle your child’s swimming confidence level at the beach/ocean: Not confident Confident Very confident EMERGENCY CONTACT DETAILS: Name: ____________________________________________ Relationship: ______________ Daytime No:_________________________ Mobile:__________________________ Evening/night No:_______________________ Address (if different to Address above) ___________________________________________________________________________ Family doctor: Name: __________________________________________________ Contact No: ____________________________ MEDICAL DETAILS: Date of last tetanus inoculation ______________________________ (current inoculation recommended) Do you have any il nesses or disabilities (ie high blood pressure, heart/lung condition, asthma, al ergy, diabetes, epilepsy, dyslexia, vision impaired, deafness)? Yes / No Please give details_________________________________________________ ___________________________________________________________________________________________________________ If you suffer from ASTHMA or an ALLERGY you MUST complete the appropriate Management Plan attached. Have you ever been hospitalised for any of the above conditions? Please give details_____________________________________ ___________________________________________________________________________________________________________ Do you currently take any form of medication? Yes / No If Yes, give details_________________________________________ ___________________________________________________________________________________________________________ Do you have any past injuries? Yes / No If Yes, give details______________________________________________________ ___________________________________________________________________________________________________________ Have you undergone surgery in the past 3 years? Yes / No If Yes, give details_______________________________________ ___________________________________________________________________________________________________________ Have you ever suffered from a stress-related il ness? Yes / No If Yes, give details_________________________________________ _______________________________________________________________________________________________________________________ Are there any other medical conditions Land’s Edge should be aware of?________________________________________________ ___________________________________________________________________________________________________________ Are there any special dietary requirements i.e. Vegetarian?___________________________________________________________ Important Notice: I acknowledge that Land’s Edge first aid kits contain the fol owing medications (Please circle medications that ARE NOT to be administered) Panadol 500mg, Imodium 50mg, Mylanta, Claratyne 10mg, Gastrolyte 5.2g, Ventolin 100mg, Senokot 7.5mg This form MUST be completed if your child is asthmatic This level of information is recommended as a minimum by the Asthma Foundation. This information wil assist Land’s Edge staff to take the appropriate precautions for your child. Seek the advice of your medical practitioner if necessary when completing this form. Student name:_____________________________________________________________________________________ Regular medication taken for asthma:__________________________________________________________________ Dosage:___________________________________________________________________________________________ _________________________________________________________________________________________________ Additional medication to be administered during an attack:________________________________________________ _________________________________________________________________________________________________ The medications listed above MUST be supplied while participating in Land’s Edge Holiday Programs. Expected best Peak Expiratory flow reading:______________________________________________________________ Peak Expiratory flow reading requiring extra medication:___________________________________________________ Peak Expiratory flow reading when advisable to seek medical assistance:______________________________________ Known trigger factors: (Please tick appropriate item) Dust of any sort, in sufficient quantities Other (please detail):___________________________________________________________________ _________________________________________________________________________________________________ LAND’S EDGE ALLERGIC REACTION MANAGEMENT FORM This form MUST be completed if your child has any known allergies This information wil assist Land’s Edge staff to take the appropriate precautions for your child. Seek the advice of your medical practitioner if necessary when completing this form. Child’s name:_______________________________________________________________________________________ Al ergic to:__________________________________________________________________________________________ What are the signs and symptoms of the reaction?__________________________________________________________ ___________________________________________________________________________________________________ What medications (if any) should be taken to prevent, or as a result of, an al ergic reaction?_______________________ ___________________________________________________________________________________________________ Please give details of medication doses___________________________________________________________________ The medications listed above MUST be supplied while participating in Land’s Edge Holiday Programs. What treatment is fol owed if an al ergic reaction occurs?____________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ Is the reaction: (Please circle your answer) A systematic reaction? (any rash, itching, swel ing away from site) An anaphylactic reaction? (severe breathing problems, swel ing of the body, emergency situation) Is there a family history of anaphylaxis? Has an al ergic reaction ever required hospitalisation? Is adrenaline (ie adrenaline injection, epi-pen) administered if an al ergic reaction is suffered? If ‘Yes’ has been answered to ANY of the above questions the fol owing steps are required before participation in Land’s Edge Holiday Programs: • Child’s Medical Practitioner must be consulted about participation in Land’s Edge programming • Child’s participation in Land’s Edge programming depends on ful agreement by Medical Practitioner, child’s parents/guardians and Land’s Edge The Medical Practitioner must be advised that: • The child may be up to half an hour from medical or hospital attention during residential programming • Al Land’s Edge staff hold first aid qualifications and wil be with the group for the duration of programming CONSENT AND INDEMNITY FORM AND RISK WARNING (To be fil ed in by parent or guardian if participant is under 18 years old) I, __________________________________________ am aware in signing this document for my daughter/son/ward’s participation in a Land’s Edge Program, that certain elements of the Program could be physical y and emotional y demanding. Furthermore, I acknowledge that in providing me with this document, Land’s Edge has warned me and/or my daughter/son/ward that certain inherent physical and/or emotional risks and dangers exist in the activities in which my daughter/son/ward wil be participating. I acknowledge that while Land’s Edge and its staff wil make every reasonable effort to teach my daughter/son/ward proper outdoor techniques and to minimise exposure to known risks, al hazards and dangers associated with these activities cannot be foreseen or may be beyond the control of Land’s Edge, its instructors or staff. I have read and fil ed in the attached Medical Form and Asthma/Allergic Reaction Management Forms. I have also read the Equipment List and wil ensure that al items listed wil be brought to the Land’s Edge Program and they wil be in good working order. I understand that this is a condition of participation in the Program. My daughter/son/ward wil ful y comply with Land’s Edge safety standards and procedures as outlined by Land’s Edge staff, operators and agents for each activity in which they participate. Failure to abide by these guidelines could compromise the safety and wel being of other participants and staff. I agree that if my daughter/son/ward suffers il ness or injury during the course of Land’s Edge activities, Land’s Edge staff, operators and agents can at my cost arrange appropriate medical treatment and emergency evacuation services, as they deem essential for their safety. I acknowledge that this agreement shal be governed in al respects by and interpreted in accordance with the laws of Australia. Student name:________________________________ Signature:_______________________________ Parent/Guardian’s name:________________________ Signature:_______________________________ Date:________________________________________

Source: http://www.youngcarersnsw.asn.au/Documents/1273_Medical.pdf