Clarification Circular - Regarding LLM Course - Kuvempu University

The Cottesloe SchoolMedical Healthcare PlanPlease complete this form if your child has any medical conditionsthat the School should be aware ofStudent’s Name: __________________________________________Reg: ____________Date of Birth: ____________________________Student’s Address: __________________________________________________________________________________________________________________________________________________Dietary Needs (please tick as appropriate):ArtificialcolourallergiesNo dairyproductsGluten freeNo nuts of anytypeHalalKosher foodsonlyNo beefNo pork No white fish RamadanSeafoodallergySugar free Vegan VegetarianOther (specify)Does your child have any of the following conditions? Please provide full details.Asthma Epilepsy DiabetesAny other medical conditions(specify)Bowel/bladderproblemsSeriousallergiesDo you consider your child to have a disability? Yes NoIf yes, please select all that apply from the list below. A child is considered to have a disability if their parent/carerindicates substantial and/or long-term difficulties with one or more of the areas listed below. Please excludedifficulties that you would expect for a child of their age.ASD/Asperger’s Behaviour CommunicationConsciousness(e.g. seizures)Eating anddrinkingHand function Hearing Incontinence Learning MedicationMobilityPalliative careneedsPersonal care Vision Other (specify)Family contact information:Name:Relationship to child:Work tel: Home tel: Mobile tel:continued overleafThe Cottesloe is committed to safeguarding and promoting the welfare of young people

Clinic/Hospital contact:Doctor’s name:Tel No:Clinic/Hospital name:GPDoctor’s name:Tel No:Surgery name:Describe medical needs and medications, and give details of child’s symptoms:Describe care requirements (e.g. before sport, at lunchtime etc.):Describe what constitutes an emergency for the child, and the action to take if this occurs:Follow up care:Who is responsible in an emergency (state if different for off-site activities)?Name:Work tel: Home tel: Mobile tel:Signed: ………………………………………………….Name: …………………………………….(please print)OFFICE USE ONLY: Date info received: ……………………. Review date: ……………………..Form copied to: 1. SIMS and school file 2. Senior First AiderThe Cottesloe is committed to safeguarding and promoting the welfare of young people