Dargavilleprimary.school.nz

Health & Permission Form
Dargaville Primary School
STUDENTS NAME …………………………………………. ROOM…………….

EDUCATION OUTSIDE THE CLASSROOM
Parents/Caregivers permission and medical information form

I give permission for my son/daughter………………………………………………….
To participate in class camp/trip at …………………………………………………….  I agree that he/she should take part in such activities and such necessary duties as may be  I authorise the obtaining on my behalf any medical assistance, if, in the opinion of the staff, such treatment is necessary, and agree to meet any costs incurred  To the best of my knowledge he/she has no medical or physical disabilities likely to prove detrimental to him/her or others during the programme  I understand that the school will not accept responsibility for loss or damage of personal  Should my son/daughter be involved in a serious disciplinary problem I accept that he/she Signature of parent/caregiver…………………………………………………………… Address……………………………………………………………………………………. Date………………………………………………………………………………………. Telephone number (day)………………………(night)………………………………… Day……………………………………………….night…………………………………. Day……………………………………………….night…………………………………. CONFIDENTIAL MEDICAL REPORT
This report is to assist us in case of any eventuality with your son/daughter. All We ask parents/caregivers to note the following requests: 1. Is your child presently taking tablets and/or medicine If YES please state the name of the medication and the dosage ……………………………………………………………………………………………… ……………………………………………………………………………… 2. All medicines must be handed to teacher-in-charge prior to leaving. It should be clearly named, have the dose to be given, and when it is to be taken. (All medicines will be kept in the first aid box and will be distributed as required) Please do not allow children to be in possession of any medicine on the trip 3. Please complete the following and return as soon as possible Child’s name…………………………………………………….Room no:……………. Parents/caregivers address……………………………………………………………. Telephone ………………………………….day ………………………………….night Please tick if your child suffers any of the following: Other………………………………………………………………………………………. ……………………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………… Last tetanus immunisation was (approx)………………………………………………. Is this the first time your child has been away from home I authorise the teacher in charge of the excursion/trip to consent, where it is impracticable to communicate with me, to the child receiving such medical or surgical treatment as may be deemed necessary. Signed……………………………………………………………………………………. Date………………………………………………………………………………………. Please note here any known health problem which may affect your son/daughter ……………………………………………………………………………………………… ……………………………………………………………………………………………… Treatment:………………………………………………………………………………… ……………………………………………………………………………………………… Medication:…………………………………………………………………………….… ……………………………………………………………………………………………. If tablets or medication are to be sent, they should be in a small bottle, labelled with the owners name and dosage. The tablets This form must be completed and returned to the class teacher by……………….

Source: http://www.dargavilleprimary.school.nz/wp-content/uploads/2013/03/healthpermission-trips-eotc.pdf