EDMUND RICE COLLEGE
EXCURSION MEDICAL INFORMATION AND CONSENT FORM
This form requests information about students which will be held by the school. This information may
be disclosed to government or private medical or para-medical staff and other relevant officers in the
event of an accident or emergency. It may also be handed on to Optimum Experiences, the
company that contracts to run some of the Outdoor Education Programmes.
Student’s Name:
Date of Birth:
School Year:
Name of Parent/Carer:
Address:
Contact Telephone Numbers: Home:
__________________________
Father:
Business Hours: ………………………………. Mobile: ………………………………………
Mother:
Business Hours: ………………………………. Mobile: ………………………………………
Medicare No: …………………………………………………...
Other Contact for Emergency: ................................................ Telephone No: ..........................................
Name of Student’s Doctor: ..................................................... Telephone No: ..........................................
Please tick () if your child suffers any of the following:
allergies
blood pressure
fainting
headaches
reaction to drugs
other, please specify______________________
anaphylaxis
diabetes
fits or blackouts
heart condition
sight/hearing problems
asthma
eczema
hay fever
nose bleeds
sun screen sensitivity
If you have ticked the allergies box above please give details of what your son is allergic to, the type of reaction to
watch for and the type of treatment required.
Allergic to: ………………………………………………………………………………………........................................
Type of reaction:………………...…………………………………………………………………………………………….
…………………………………………………………………………………………………............................................
Type of treatment:…………………………………………………………………………………………………………….
………………………………………………………………………………………………………………………………….
If you have ticked any of the boxes above and you or your son’s Doctor believe it necessary please provide an Emergency
Treatment Plan.
NB. Without an Emergency Treatment Plan the school can only provide general first aid treatment.
Date of last tetanus injection:
___/___/___
Is the student presently taking any medication?
Yes
No
If YES, please state name of medication, dosage, etc:
Name of medication: …………………………………………………………………………………………………………
Dosage :……………………………………………………………………………………………………………………….
p.t.o.
The teacher in charge must be informed about the management of any medication prior to 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 students name, dosage and frequency of administration.
Please note: Management of Medical Conditions
The College is committed to providing a safe and healthy environment for students. While school staff have a duty of care to
students to provide first aid assistance when required, parents should be aware that teachers cannot be responsible for the
general management of medical conditions.
In special circumstances, staff may be able to assist with the administration of medication. In these cases, College policy
requires parents to provide written authority accompanied by a statement from the student's doctor authorising a member
of staff to administer the prescribed medication.
Are you aware of any other relevant circumstances that may affect your child’s ability to participate in activities
organised by the school? Please give details.
........................................................................................................................................................................................
.........................................................................................................................................................................................
Special Dietary Needs
Vegetarian
Vegan
Other (please give details)
No pork
No dairy products
……………………………………………………………………………………………………………
Swimming Activities
Swimming Ability: I rate my son’s swimming ability to be:
Non-swimmer
Weak swimmer (<50m)
Fair swimmer (50–100m)
Strong swimmer (200m+)
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 or treatment as outlined in an emergency treatment plan and I further authorise the school, where it
is impracticable to communicate with me, to arrange for him/her to receive such medical or surgical treatment as may
be deemed necessary, including transport by ambulance. I consent to my child’s doctor or medical specialist being
contacted by medical personnel in an emergency.
Signed: ............................................................................... (Parent/Carer)
Date: …………………………..
Please note that it is the parent/caregiver’s responsibility to notify the College in writing of
any change to a student’s physical condition that may alter their ability to participate safely
in an activity.