2021-2022_Woodland health form v.202105 - WMA

STUDENT HEALTH DECLARATION FORM

This Form is to be completed by all NEW students and returned to the School by the parents/ guardians PRIOR to the student’s actual commencement at the School.

In addition, this Form is to be completed annually by all RETURNING students and returned to the School by the parents/ guardians PRIOR to the student’s commencement of the relevant academic year at the School.

*Required field

Full Name of Student*

First Name

Last Name

Student's Date of Birth*

Full Name of Parent / Guardian 1*

First Name

Last Name

Full Name of Parent / Guardian 2

First Name

Last Name

Contact Email of Parent / Guardian 1*

Contact Phone Number of Parent / Guardian 1*

Please enter country code for non-local number.

Contact Email of Parent / Guardian 2

Contact Phone Number of Parent / Guardian 2

Please enter country code for non-local number.

Class (if known)

Name of Family Doctor (optional)

First Name

Last Name

Contact Phone Number of Family Doctor (optional)

Please enter country code for non-local number.

Enrolment Status*

New Student Returning Student

Has your child had any serious illness, injuries or surgeries such as fractures/dislocations, concussions, hospitalisation in the past?*

Yes No

Please provide further information in relation to the serious illness, injuries or surgeries such as fractures/dislocations, concussions, hospitalisations.

Has your child had any serious illness, injuries or surgeries such as fractures/dislocations, concussions, hospitalisation in the last 12 months?*

Yes No

Please provide further information in relation to the serious illness, injuries or surgeries such as fractures/dislocations, concussions, hospitalisations.

Please provide a copy of your child’s immunisation records showing your child's name (in English)*

No File Chosen

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Max 5MB

If name is not visible on the above document, please upload the cover showing your child's name.

No File Chosen

File uploads may not work on some mobile devices.

Max 5MB

Does your child have any Allergies?*

Severe Allergies (go to Form1.1 - Severe Allergies) Mild Allergies None

Please list any allergies your child may have. Please include the signs, symptoms, and treatment required.

Form 1.1 - SEVERE ALLERGIES

Anaphylaxis/Allergy Parent Questionnaire.

Please complete this form regarding your child’s allergy. This information will be used to develop a health plan, if necessary, and shared with appropriate staff.

Your input is extremely important. Thank you for your time.

What is your child severely allergic to? *

Allergic reaction with (please select):*

Contact Ingestion

Symptoms your child presents with after contact/ ingestion?*

How was this allergy diagnosed? *

Date of last allergy test and results.*

Has your child required treatment in an emergency department related to allergy?*

Yes No

If yes, please give date/age and brief description.

What is the treatment required for your child in case of a severe reaction? (please select or describe) *

Epi-Pen Antihistamine

Other:

Please provide the Name and Dose of Antihistamine.

Signature of Parent / Guardian*

[clear]

Use your mouse or finger to draw your signature above

Does your child have any respiratory issues, e.g. Asthma?*

Yes No

Please provide further information in relation to your child’s respiratory condition including triggers, treatment and any medication required.

Does your child have any Skin Condition/Issues e.g. eczema? *

Yes No

Please provide further details of your child’s Skin Condition/Issues including treatment and any medication required.

Does your child have any other medical conditions e.g. ADHD, Autism or recurrent illness?*

Yes No

Please provide further details of any other medical conditions your child may have including treatment and any medication required.

Does your child have any vision issues/condition or wear glasses?*

Yes No

Please provide more information in relation to your child’s vision issues/condition.

Does your child have any hearing loss/issues?*

Yes No

Please provide further information in relation to your child’s hearing loss/issues.

Does your child have any special dietary requirements e.g. food intolerances, no pork, vegetarian, no beef?*

Yes No

Please provide further details of your child’s special dietary requirements.

Does your child take any daily medication at home?*

Yes No

Please provide details of your child’s medication taken at home including the name of the medication, the dosage and the frequency.

Is your child required to take any medication while attending at the School?*

Yes No

Please provide details of your child’s medication to be taken at School including the medication name, dosage and frequency.

Is there any further health and medical information of your child not already mentioned above that the School or Teacher should be aware of for the safety and well-being of your child?*

Yes No

If so, please describe:

Consent to Treatment*

I/We, the parents/ guardian, consent for the School to provide first-aid to my/our child while attending the School in case of any medical emergency. If immediate medical observation and/or treatment is deemed necessary in the judgement of the School First Aider, I/we authorize and direct the School to send my/our child to Health Care Professionals or Hospitals most readily available. I/we declare that all the student health and medical information that I/we have provided in this Student Health Declaration Form is true, accurate, complete, comprehensive and up-to-date. I/we consent to the School’s collection, use and disclosure of any such student health and medical information to any third party who is acting on behalf of the School in the provision of teaching, events and activities, whether through camps, outdoor education or field trips forming part of the School curriculum.

Parents/ guardians *

By marking this tick box, I/we hereby declare that I/we am/are the parents/ guardians identified above and agree that my/our marking of this tick box is intended to be equivalent to applying my/our personal written signature on this document and may be relied upon by the School to the same extent. Further, by marking this tick box, I/we declare that all the information submitted by me/us in this document is true, accurate, complete and up-to-date and I/we hereby accept and agree to be bound by all the terms and conditions of this document.