Excursion Medical Information
and Consent Form

This form is intended to be used to assist the school in the case of any medical treatment required or medical emergency involving a student on a excursion involving day travel beyond the ACT or an excursion including overnight accommodation regardless of the distance from the school. It is also intended to be used for an overseas excursion, sports and all outdoor adventure activities. A copy of each student’s form must be taken along on the excursion. The Department collects the information contained in this form to provide or arrange first aid and other medical treatments for students. The information collected will be held at your child’s school and will be made available to staff of the school and to medical or paramedical staff in the case of an accident or emergency. The information contained in the form is personal information and it will be stored used and disclosed in accordance with the requirements of the Privacy Act 1988 (Commonwealth). Parents/carers must note that in the absence of an Emergency Treatment Plan only standard first aid will be administered.

Student’s name:

Ambulance fund:	NOTE: Parents/carers are responsible for ambulance costs outside the ACT.

Please tick the relevant box(es) below if your child suffers from any of the following:

allergies anaphylaxis asthma blood pressure	diabetes eczema epilepsy fainting	fits or blackouts hay fever headaches heart condition	motion sickness muscular/skeletal complaint	nose bleeds reaction to drugs sight/hearing problems sunscreen sensitivity

other:

If you have ticked any of the boxes above, an Emergency Treatment Plan must be provided. Proforma plans are available from the school. NOTE: The school will provide standard first aid treatment only unless an Emergency Treatment Plan is provided.

Date of last tetanus injection:

Has the student suffered from any acute illness or injury or been treated by a medical practitioner for an illness or injury during the last 4 weeks?	Yes No

If YES, please state nature of illness/injury and obtain a report from the doctor that the student is fit to undertake the camp/excursion

Is the student presently taking any medication?	Yes No

If YES, please state name of medication, dosage, etc.:

The teacher-in-charge must be informed about the management of any medication before leaving on an excursion. Arrangements need to be agreed on the transport, storage and administration of medication. In all cases, medication must be labelled with the student’s name, dosage and frequency of administration.

I consent to my child receiving paracetamol for temporary pain relief. I consent to my child receiving ibuprofen.	Yes No Yes No

Please list any of your child’s dietary requirements: ………………………………………………………………………….........................

Are you aware of any physical or psychological limitations of your child? Please give details.

Consent to medical attention: In the case of my child requiring medical treatment or in the case of a medical emergency, I consent to the school providing first aid (and, if applicable, treatment as outlined in the Emergency Treatment Plan I have provided to the school). I further authorise the school, where it is not practicable to communicate with me, to arrange for my child to receive such medical or surgical treatment as may be deemed necessary. I also undertake to pay any costs that may be incurred for the medical treatment, ambulance transport and drugs relating to my child.

Emergency Treatment Plan

I have attached an Emergency Treatment Plan Yes No If yes, indicate date of plan and doctor’s name and contact information.

Parent/Carer signature:	Date: