HEALTH AND PERMISSION FORM

Education Outside the Classroom

Please return by Wednesday 4th of March 2015
Students Name ________________________________________
Homebase _________________
I give permission for my son/daughter _____________________________________
to par6cipate in the Year 5/6 camp at Living Springs Camp, 218 Bamfords Rd, Allandale, RD1, LyGelton 8971
from the 4th - 6th of May (Red Zone) or the 6th - 8th of May (Green Zone).
I agree that he/she should take part in such ac6vi6es and such necessary du6es as may be required by the
sta.

I authorise the obtaining on my behalf any medical assistance, if, in the opinion of the sta, such treatment is
necessary, and agree to meet any costs incurred.
To the best of my knowledge he/she has no medical or physical disabili6es likely to prove detrimental to him/her
or others during the programme.
I understand that Clearview Primary will not accept responsibility for loss or damage of personal property (check
own household insurance policy).
Should my son/daughter be involved in a serious disciplinary problem I accept that he/she may be sent home at
my expense.

Signature of parent / caregiver _________________________________________ Date ___________________

Address _____________________________________________________________________________________
Contact telephone numbers
Home ________________________________________
Emergency numbers Day ____________________ Name _______________

Night ____________________ Name _______________

Student Contract:
I understand that this event is an opportunity for me to learn new things, and prac6se skills, and gain a^tudes and
values in an environment outside the classroom. I will need to be responsible for my own learning and safety and that of
others. This means that I will:
show courtesy and considera6on for others
follow the rules and instruc6ons of teachers and supervisors
take part in all ac6vi6es within challenge-by-choice op6ons
look a`er myself and my belongings
declare medical condi6ons that could aect my par6cipa6on
accept the rules for the event, even if they are dierent from the ones we have at home.
I understand that my parents/caregivers will be contacted, and I may be sent home at their expense, if:
sta consider my ac6ons unacceptable
my ac6ons put me or others in danger.

Signature of student __________________________________________________ Date ___________________

CONFIDENTIAL MEDICAL REPORT

This report is to assist us in case of any eventuality with your son/daughter. All informa6on is held in
condence. We ask parents / caregivers to ll in the following informa6on.
1. Is your child presently taking tablets and/or medica6on YES / NO
If YES, please state the name of the medica6on and the dosage

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
2. All medicines must be handed to the teacher-in-charge prior to leaving for camp with your childs NAME,
the DOSE, and WHEN it should be taken. (Medicines will be kept in the rst aid cabinet and distributed as
required)
3. Please complete the following informa6on and return to school as soon as possible
Please 6ck if your child suers from any of the following
Bed we^ng [ ]
Fits of any kind
[ ]
Heart condi6on
[ ]
Dizzy spells [ ]
Sleep walking
[ ]
Asthma

[ ]
Blackouts
[ ]
Migraines

[ ]
Travel sickness
[ ]
Diabetes
[ ]
Other

________________________________________________________________________________________
Allergies
[ ]
Any foods

[ ]
Any drugs

[ ]
________________________________________________________________________________________
________________________________________________________________________________________
Is there any special care that is recommended?
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Swimming ability:
My child can swim 50m on his/her own without stopping [ ]
My child cannot swim 50m on his/her own without stopping

[ ]

Last tetanus immunisa6on was ______________________ This is up-to-date YES / NO

Is this the rst 6me your child has been away from home YES / NO
I authorise the teacher in charge of the excursion to consent, where it is imprac6cable to communicate with
me, to the child receiving such medical or surgical treatment as may be deemed necessary.
Signature of parent / caregiver _______________________________________ Date ______________
Rela6onship to child _____________________________