The information on this form will remain confidential to the teachers/instructors in charge of/assisting with the camp. However, in the interests of the safety of all involved, any life-threatening conditions may be made known to other students. Please be assured that your child’s physical and emotional well-being always remains of paramount importance to us.
Student's Full Name *
Students AT or Homeroom: * Q1.
Please tick if your child suffers from any of the following:
Is your child currently taking any medication?
If you selected Yes to Q2:
Please state the following in the box below:
Ailment(s) / Name of Medication / Dosage and Time(s) to be taken / Other Treatment
Has your child had any major injuries (breaks or strains) or illness (glandular fever etc) that may limit full participation in any activities?
(If Yes, please complete in the box provided below).
Is your child allergic to any of the following?
If you selected any of the boxes in Q4:
Please specify severity and treatment below:
Q5. Can your child confidently swim 20 metres? * Q6.
Outline any special dietary requirements. Please be specific, eg. vegetarian, lactose intolerant etc.
Is there any medication your child is NOT able to be given?
To the best of your knowledge, has your child been in contact with any infectious diseases in the last four weeks? If yes, please detail below:
Is there any information that your child's teacher and staff should know to ensure the physical and emotional safety of your child?
(for example cultural practices, disability, anxiety, behavioural problems, phobias about height/small places etc).
Parent/Caregiver Information: Parent/Caregivers Name *
Parent/Caregivers Email *
Please enter a valid email address to receive a emailed version of this form once completed.
Parent/Caregivers Mobile * Parent/Caregiver Consent
Please tick the boxes below to complete the Parent/Caregiver Consent.
* * * * * Parent/Caregiver Signature * Date *
DD slash MM slash YYYY