Health profile and medical consent

This profile is designed to assist with the care of all participants on EOTC events, including
adults. One form to be completed for EACH participant.
Name: Medic Alert Number:
(if applicable)
1. Please tick if you have any of the following:
Migraine Epilepsy Asthma
Diabetes Travel sickness Fits f any type
!hrnic nse bleeds "eart cnditin Di##y spells
!lur blindness $ther (%lease specify)
AD"D
For overnight events
&leep'alking (ed'etting
2. Are you/your child currently taking medication )es N
*f )E&+ please state: "ealth cnditin,s:
Name f medicatin,s:
Dsage and time,s t be taken:
$ther Treatment:
!. "s a health plan re#uired )es N - t &ample frm .
"ave yu had any ma/r in/uries (breaks r strains) r illness (glandular fever etc) in the last si0 mnths
that may limit full participatin in any activities1
)es N
*f )E&+ please state the in/ury,illness:
$. Are you allergic to any of the following
)es N %lease specify
%rescriptin medicatin
Fd
*nsect bites,stings
$ther allergies
%miths Avenue &iddle %chool
'lass !A
(ike %afe (ike %mart 'ycling Program
%ample Form ) <Insert school namelogo here!
2hat treatment is re3uired1
*. +hen was your /your child,s last tetanus in-ection
.. /utline any dietary re#uirements:
). +hat pain/flu medication may your child 0e given if necessary
1. 2o the 0est of your knowledge. Have you/your child 0een in contact with any contagious or
infectious diseases in the last four weeks
)es N
*f )E&+ please give brief details
3. "s there any information the staff should know to ensure the physical and emotional safety of
you/your child 4For e5ample cultural practices6 disa0ility6 an5iety6 a0out
heights/darkness/small spaces6 pregnancy6 0ehaviour or emotional pro0lems7.
)es N
*f )E&+ please state r attach the infrmatin4
Tick
* agree that if prescribed medicatin needs t be administered+ a designated adult 'ill be
assigned t d this4 * 'ill ensure that prescribed medicatin is clearly labelled+ securely fastened
and handed t the designated adult 'ith instructins n its administratin4
* 'ill infrm the schl as sn as pssible f any changes in the medical r ther circumstances
bet'een n' and the cmmencement f the event4
* agree t my child,myself receiving any emergency medical+ dental+ r surgical treatment+ including
anaesthetic r bld transfusin+ as cnsidered necessary by the medical authrities present4
Any medical csts nt cvered by A!! r a cmmunity service card 'ill be paid by me4
*f my child is invlved in a serius disciplinary prblem+ including the use f illegal substances and,r
alchl+ r actins that threaten the safety f thers+ s,he 'ill be sent hme at my e0pense4
2o 0e read and signed 0y adult participant or parent/caregiver of child participant.
&ignature:
Name: Date: