Additional Child Medical Information Form

Additional Child Medical Information Form

*Please note - If you have multiple children you will need to fill out a separate Medical Information Form for each additional child.

ADDITIONAL CHILD'S DETAILS :

First Name :(*)

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CHILD's Centrelink Reference Number (CRN)
Please note: Parent and child have their own individual CRN number(*)

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Family Name:(*)

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DOB:(*)

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MEDICAL INFORMATION:

Education and Care Services National Regulations - Regulation 160 (3a, I, j)

Please outline any dietary restrictions?
A dietary form will be issued by the service and further discussion

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Anaphylaxis/Allergy Action plans to be completed by a Medical Practitioner on the ASCIA template form.

Please provide details below

Name of medical specialist:

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Address:

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Phone contact:

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If your child has diagnosed allergies or anaphylaxis please supply medication as outlined on your child’s management plan & ensure the form is accurate and signed by a medical practitioner.

Asthma

Does your child take regular Asthma medication?(*)

YesNo

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If yes, please provide details:

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A Child’s Asthma Record will need to be completed to identify standard asthma first aid plan or a copy of the formal asthma plan.
Please supply an inhaler spacer and prescribed medication/Ventolin as outlined on your child’s management plan.

MEDICATION AGREEMENT

Medication will only be administered if it is in the expiry or use by date, original packaging, labelled and instructions that can be clearly read. The service medication form must be completed by the parent/guardian for medication to be administered by staff. Additionally, if the medication has been prescribed by a medical practitioner:

The label must contain the child’s name
Parent/Guardian must provide any verbal or written instructions provided by the medical practitioner.

Parent/Guardian 1
Signature:(*)

Sign Above

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Parent/Guardian 2
Signature:

Sign Above

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*Do you authorise the Nominated Supervisor or another educator at the service to seek medical treatment from a registered medical practitioner, hospital or ambulance service?(*)

YesNo

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Parent/Guardian 1
Signature:(*)

Sign Above

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Parent/Guardian 2
Signature:

Sign Above

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*Do you authorise the Nominated Supervisor or other educator at the service to seek dental treatment from a registered dental practitioner or service in the event of an emergency?(*)

YesNo

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Parent/Guardian 1
Signature:(*)

Sign Above

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Parent/Guardian 2
Signature:

Sign Above

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Child’s Registered Medical Practitioner or Service Details:

Medicare Number:(*)

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Medicare Expiry Date:(*)

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Private Health Fund Name:

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Ambulance Cover:(*)

YesNo

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Service Name:(*)

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Practitioner’s Name:(*)

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Practitioner’s/Medical Service Address:(*)

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Contact Numbers:(*)

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IMMUNISATION DETAILS/HEALTH: ADDITIONAL CHILD

Are your child’s immunisations up to date?(*)

YesNo

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Please provide a copy of your child's: Immunisation History Statement

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Please sign:(*)

Sign Above

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Do you authorise the Nominated Supervisor or other educator to transport the child in an ambulance in the event of an emergency?(*)

YesNo

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Parent/Guardian 1
Signature:(*)

Sign Above

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Parent/Guardian 2
Signature:

Sign Above

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Please be advised that if the child is diagnosed with asthma or anaphylaxis and an emergency occurs, the Responsible Person or educators may administer emergency first aid without making contact. Educators will notify the child’s parents and/or emergency services as soon as possible.(*)

YesNo

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Parent/Guardian 1
Signature:(*)

Sign Above

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Parent/Guardian 2
Signature:

Sign Above

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DEVELOPMENTAL INFORMATION - ADDITIONAL CHILD:

Does your child have any difficulties with hearing, sight or speech?(*)

YesNo

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Please provide details:

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Does your child have a physical disability or delay, including intellectual, sensory or physical impairment?(*)

YesNo

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Please provide details:

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Provide us with any other information we should know about your child. Please assist your child to complete the About You form which will provide our educators with further information on your child’s interest. (e.g favourite family activities, free time, strengths etc.)

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STAYING IN BOUNDS - ADDITIONAL CHILD:

We have expectations that children will be responsible and stay in the designated areas within the school grounds.
Each session (morning/afternoon) children are informed by staff educators which areas are open.
If families have concerns with their child wandering and going out of bounds please discuss with us.

Are you confident your child can follow these guidelines?(*)

YesNo

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If no, please discuss with the Centre Manager/Nominated Supervisor

Parent/Guardian Name:(*)

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Parent/Guardian Email Address:(*)

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Parent/Guardian Signature:(*)

Sign Above

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