Student Medical Form

Please find below our Student Medical Form which needs to be completed before your student participates in any Interschool Sport. The personal details requested are to enable our College to make contact with you in the event of an emergency and are strictly confidential.

Student Details:

Student Name

Date of Birth

Home Address

Parent/Guardian Details:

Parent/Guardian Name:

Mobile

Parent/Guardian Name:

Mobile

Any relevant family history

Student Medical History + Authorisation

Medicare Number

My son/daughter has been immunised against (please show year immunised, if known)

Date of last anti-tetanus injection

Name of private insurance company if insured against injury

Is your son/daughter suffering from an injury that is likely to be aggravated

Yes

If YES, please provide details about the injury or condition

Any relevant medical history

I hereby authorise the obtaining on my behalf of such medical assistance as my son/daughter may require in the event of accident or illness. I authorise administering of anaesthetic if the medical officer attending deems this necessary.

Thank you for completing our Medical Form. This information has been sent to our Sports Department to be kept on their records.