Medical Family Information Form
Protecting your privacy is important to us. The information we seek allows us to manage risk, provide reasonable care and administer your involvement in our program. We are careful to keep your information confidential, and provide it only to those agents acting on behalf of the organisation who need it to enable them to perform their agreed activities (e.g. the First-Aider-In-Charge). You are welcome to contact our office in relation to issues regarding your personal information and for a copy of our Church Privacy Policy.
We only ask for information that is necessary for the purposes outlined in this statement. In some circumstances, if you don't provide us with all requested information, you could miss the opportunity to be involved in our program.
Part A
Part A contains information about the parents and medical details around insurances. Medical Information for the adults in a family should be completed using the Personal Medical Information Form (18+).
Personal Contact Details:
Emergency Contact Details:
Medical Information:
Part B
Part B contains Information about each child in the family. After completing Part B, scroll or slide to the bottom of the page. Tap the SUBMIT button if you only have one child OR tap the BLUE ADD Another Person Button to add another child.
For additional children just complete Section B of the form
Information on Relevant Conditions:
Are there any conditions which require special attention that we should know about, e.g. hearing or sight impairment, mental health issues, formal counselling situations, or any other?
Program Preparation Details:
Medical Information:
Prescribed medication will be administered by a designated leader if it has been provided, clearly labelled in its original packaging and has a doctor’s instructions on it.
Important: Please note that in regards to non-prescription medications such as paracetamol (e.g. Panadol), it is our policy that leader team members do not provide medications.
Specific Medical Conditions:
Please indicate if your child has had any of the following conditions:
Information on Relevant Conditions:
Particular Activities:
In attending this program or event, you consent to participation in a range of general sporting and recreational activities. If potentially risky activities of a specific nature are included, the Team Leader will inform you of these.
Your Agreement:
I am aware, in submitting this document regarding my child/ren's participation in this program, that certain elements of the program could be physically and emotionally demanding. Furthermore, I understand that certain inherent risks and dangers exist in the activities in which they will be participating. I acknowledge that while the organisation and its leaders will make every reasonable effort to minimise exposure to known risks, all hazards and dangers associated with these activities cannot be foreseen or may be beyond the control of the organisation, its leaders and staff. In the event of any emergency where my nominated contact people are unavailable:
- I authorise the leaders to obtain medical advice and/or assistance which they deem necessary.
- I further authorise qualified practitioners to administer anaesthetic if required.
- I accept all operation, blood transfusion and/or anaesthetic risks involved in the event that such procedures are
deemed necessary.
- I accept the responsibility for payment and agree to pay medical, transport and any other related expenses.
- I confirm that the information contained in this application is true and correct.
- I agree to inform the leader of any change to these details.
