2020 Senior Academy Medical/Behavioural/Dietary Form Senior Academy Diet/Medical/Behavioural 2020 Please complete as soon as possible Step 1 of 3 33% Student InformationThe purpose of this form is to allow us to adequately prepare for your safe participation in this activity. ALL INFORMATION PROVIDED HEREIN WILL BE KEPT STRICTLY CONFIDENTIAL.Student Name* First Last Student DOB* DD slash MM slash YYYY Student Mobile(If no phone, leave blank)Student Gender M / FMedicare Number Doctor's name and contact number (e.g. Dr Smith Ph 0444 444 444)Parent/Next of Kin* First Last Relationship to Student Parent/Next of Kin email* Parent/Next of Kin Emergency Contact Number(In case of emergency) General Medical/Disability/AsthmaDoes the student have any disabilities or illnesses?*YesNoIf yes, please provide a general overview:If no, please leave blankDo you suffer from Asthma?*YesNoIf yes, please provide information on regular medication and dosage, including additional medication to be taken during an asthma attack:If no, please leave blank. It is important that we have the following information to help us to take the best precautions for your safety. This level of information is recommended as a minimum by the Asthma Foundation. Please obtain advice from your medical practitioner if necessary when completing this section. In the case of an emergency where we cannot for any reason contact your nominated next of kin, Academy administration staff will take the appropriate action, ie call an ambulance or take the student to the nearest hospital emergency department. Known trigger factors (please indicate any appropriate item) Dust Contact with animals Sudden change in temperature Grass, weeds, pollen, mould Vigorous exercise Other Food Allergies/IntolerancesAll medications should be carried at all times by the sufferer, and administration of the medication/s is to be at the student's own responsibility and risk. In the case of an emergency where we cannot for any reason contact your next of kin, Academy administration staff will take the appropriate action, ie call an ambulance or take the student to the nearest hospital emergency department. All information provided will be kept strictly confidential.Does the Student and/or Parent/Guardian have any FOOD ALLERGIES or INTOLERANCES??*YesNoWe must provide food allergy/intolerances to our caterers in order to ensure food safety for all. Our caterers are very highly experienced in catering for any and all issues (lactose, gluten, FODMAP, allergies of all kinds, and much more), so please let us know so that we can ensure there is something for everyone. In all the years of Academy, we have not yet met an allergy/intolerance we've been unable to cater for.If yes, please provide details:If no, please leave blankDoes the student have any other non food related allergies?*YesNoIf yes, please provide details:If no, please leave blankWhat medication do you take (if any) for the prevention against allergic reaction? What treatment is to be followed if an allergic reaction occurs (Includes Epi Pen)Allergy reaction treatmentPlease provide below any other information regarding any health issues that you feel is relevant:If nothing further, please leave blank.Transport - If under 18 only Yes No I give permission for my child/ward to travel with Academy staff/organises when required. Behavioural Code of Conduct* Yes No I have read and understood the Academy Behavioural Code of Conduct as stated on the website. I understand that if the rules are broken it may result in my dismissal from the Academy.Parent / Guardian DeclarationIn accepting my attendance at the 2020 Senior Academy of Country Music in the case of an emergency, I authorise the Academy organisers/staff, where it is impracticable to communicate with me, to contact my next of kin and arrange for me to receive such medical treatment as may be deemed necessary. I also undertake to pay or reimburse costs which may be incurred for medical attention, ambulance transport, and drugs and other costs while I am enrolled in the Academy. I understand that although the organisation tries to minimise any risk of personal injury within all practical boundaries, accidents do happen and all physical activities carry the risk of personal injury. I acknowledge that there is an inherent risk of personal injury in physical activities that will be undertaken as part of this event/activity/program. By clicking on "Submit" below, you acknowledge the above.Permission* Yes No Δ
