Australia Zoo - Student Excursion Consent Form

30 Beerburrum Road
CABOOLTURE 4510
PO Box 1185
CABOOLTURE 4510
Phone: 07 5495 2266
Fax: 07 5495 8315

Year 1 Excursion to Australia Zoo

Date:_______________________________Class:____________________________________
Parent/Person with Legal Responsibility for the Student Consent Form
As a Parent/Person with legal responsibility for the student of:
____________________________________________________________________________________________
(Childs first name and surname)
____________________________________________________________________________________________
(Your first name and surname)
give my consent for him/her to participate in the school activity as detailed in the written information supplied to me. I
am aware of the nature of the activity and agree to delegate my authority to the staff and instructors involved.
I accept that the teachers and instructors will take appropriate disciplinary action necessary to ensure the safety, wellbeing and successful conduct of the students who participate in the activities associated with the excursion.
In the event of any illness or accident, I authorise the obtaining of such medical assistance as my child may require. I
accept all medical treatment, blood transfusions and/or anaesthetic risks involved and the responsibility for payment of
any expenses thus incurred.
I include the completed medical information section (below) about my child to assist those who are organising the
excursion.
Signed:_____________________________________________________ Date:____________________________
(Parent/Person with legal responsibility for the child)
Emergency contact telephone number: ____________________________________________________________

Medical Information: (Please note - Where * is used, please delete as appropriate)

Does your child have any medical condition or disability which may affect your childs participation in the school
excursion? Yes/No* If Yes, please give details:

Is your child on any prescribed medication(s) which would be required to be continued during the excursion? Yes/No*
If Yes, please give details:

Does your child have any allergies (eg. insect bites, food)? Yes/No* If Yes, please give details:

Is there any other information you would like to give which, in your view, may affect your childs participation in the
excursion? Yes/No* If Yes, please give details:

ASTHMA MANAGEMENT PLAN

To be completed by the parent/guardian of a child who suffers from asthma. If your child does not
suffer from asthma, please disregard this form.

Students name:____________________________________________

Male / Female

Parent/Guardian phone no: Home _______________________________Work____________________________

Medical Information:
Name of Doctor treating your child for asthma:___________________________________Ph:_____________________
HOW SEVERE IS YOUR CHILDS ASTHMA?
Your child requires asthma medication most weeks of the year?
Your child wakes regularly at night with asthma?
Has your child required urgent medical attention for asthma in the past year?
Is your childs peak flow consistently below expected, despite optimal treatment?

Yes / No
Yes / No
Yes / No
Yes / No

PEAK FLOW
Does your child have a peak flow meter?
What is their normal reading?

Yes / No
Yes / No

WHAT ARE THE TRIGGER FACTORS FOR YOUR CHILDS ASTHMA

Is your childs asthma triggered by any of the following factors?
Dust
Yes / No
Pollens
Yes / No
Plants
Yes / No
Moulds
Yes / No
Animal Fur
Yes / No
Fuel Fumes
Yes / No
Cold Conditions Yes / No
Exercise
Yes / No
Food Preservatives
Flavourings (e.g. MSG)
Artificial food
Specific food or food groups (e.g. wheat or dairy products)?
Any other known triggers of additional information?
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Plan of Management:
In order to give assistance to a student in distress, we need to know the following information and a preventative plan
of management.
Summarise a prevention plan of management to undertake to prevent the onset of a major attack.
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
What are the warning signs for the onset of a major attack?
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Outline the best strategies for obtaining relief of the attack
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
What asthma medication does your child take? (please circle the preventer or reliever medication used by your child)
Preventers:

Becotide, Becloforte, Aldecin, Pulmicort, Intal, or Intal Forte

Other (please specify)_________________________________________

Reliever:

Bricanyl, Respolin, Ventolin, or Atrovent

Other (please specify)__________________________________________

Please indicate if you would like your childs asthma medication to be kept in the health room or with them at
all times____________________________________________________________________________________

Date:

Signed: