Muritai School Health Information and Permission Form 16th October 2012

Dear Parents/Caregivers
We need information about each students health as part of our preparation and
management of the Abel Tasman Adventure. We also need your formal authorisation
of their involvement in activities. Please complete all sections of this form and return
by Friday 2th November.
Thank you
Stu Devenport (Any enquiries contact me on Wk: 562 0041 or 562-8409)
Email: devenport@muritai.school.nz
Students name............................................................................................
I give permission for my child to participate in the Abel Tasman Adventure 2012 at
Abel Tasman National Park from Sunday 9th December to Friday 14th December
2012.
I agree that she/he should take part in any activities and duties required by
the staff.
I authorise the obtaining and provision of medical assistance for her/him, if
such treatment is considered necessary and I agree to meet any costs incurred in
doing this.
I advise that to the best of my knowledge she/he has no conditions or
disabilities likely to prove detrimental to her/him or others during the Adventure.
I accept that my daughter/son may be sent home at my expense if she/he
presents a serious disciplinary problem.

I understand that the school will accept no responsibility for any loss or
damage to her/his property. (check own household insurance policy)
Parents/Caregivers name..........................................................................
Signature........................................................

Date...

Parent contact details

I can be contacted at one of the following numbers:
Day.. Evening.. Mobile..........
E-mail.
Emergency contact
If I am not able to be contacted please contact the following person instead:
Name.............................................................................................................
Day.

EveningMobile............................

Health Information (Confidential)

Medication
Does your child regularly use any medication?

yes

no

(circle one)

If yes please state the condition being treated, the name of the medication and
dosage
...........................................................................................................................
...........................................................................................................................
During the trip all medicines will be held by the teacher-in-charge and distributed as
required. (Carole Lowe will hold all medication)
If your child needs to carry any medication on them, for example an asthma inhaler,
please state:
...........................................................................................................................
You will be asked to update the information about medication just prior to
departure.
Medical conditions
Does your child experience any of the following (circle yes or no)
Heart condition Fits of any kind Sleep walking -

yes no
yes no
yes no

Asthma - yes no
Migraine
yes no
Blackouts - yes no Dizzy spells yes no
Bed wetting - yes no Travel sickness- yes no

Other (please state)..........................................................................................

If yes to any please describe what preventive action, special care or response is
required.
..........................................................................................................................
..........................................................................................................................
Allergies/Food requirement
Does your child have any allergies to food or medication, or special food
requirements such as vegetarian only - yes no (circle one)
If yes please detail:
..........................................................................................................................
Tetanus immunisation Important date required
Date of last tetanus injection............................................................................
If your childs tetanus immunisations are not up to date do you give permission to
obtain a tetanus injection if the need arises.
Other health issues
If there are any other matters you believe we need to be aware of please state

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