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PERSONAL INFORMATION

STUDENT’S NAME                                                                             D.O.B.                                    

ADDRESS                                                                                                                                                                                                                                                                                                     

PHONE NUMBERS:                                                                                                              

MEDICARE NO:                                                         

DETAILS OF PRIVATE HEALTH INSURANCE (IF ANY)

(FUND NAME)                                                                       (M’SHIP NO)                                     

MEDICATION INFORMATION

Is your child currently on medication?                    Yes/No

Is your child taking medication with him/her?        Yes/No

If yes, provide details:                                                                                                                                                                                                                                   

Does your child require scripts?      Yes/No            Is s/he taking any with her/him?     Yes/No

IN THE EVENT OF YOUR CHILD HAVING A HEADACHE, do you give permission for the administration of medication such as paracetamol or aspirin (examples only)?  Yes/No

If yes, which brand of tablets (can be any) and how many?                                             

DATE OF LAST TETANUS SHOT          /             /

DETAILS OF ALLERGIES/DISABILITIES/MEDICAL CONDITIONS:                                                                                                                                                                                                                                                                                                                                                                                             

I understand that while everything is done to ensure both the comfort and safety of the students on the Port Macquarie Excursion, and whilst every care will be exercised by those who are in charge, the Wollongong Conservatorium of Music accepts no responsibility in any way for any accident or sickness that may occur through any circumstance.

I authorise the Supervising Staff Member(s) of the Wollongong Conservatorium of Music, in the event of any accident or illness, to obtain all necessary medical assistance if I am unable to be contacted. I agree to pay all doctor’s hospital fees and expenses incurred on behalf of the said student. In the event of an emergency necessitating the performance of an urgent surgical procedure on the student, I hereby authorise such a procedure and the administration of anaesthetic provided that a qualified practitioner administers such medical treatment.

I understand that the Wollongong Conservatorium of Music does not accept any responsibility in any way for any theft, loss or damages to personal equipment such as musical instruments, cameras, mobile phones, etc.

Signature of Parent/Guardian                                                                                            

Dated:                                                                                                                        

Emergency contact telephone numbers (and names). Please list as many as you feel necessary.

I agree to accept the directions of the Staff Members of the Wollongong Conservatorium and to respect their organisation during the time of this excursion. I appreciate that my safety and the safety of the group will at all times be a priority. I agree to always notify staff of my whereabouts and respect that the tour is drug and alcohol free.

Signature of Student                                                                                                           

Signature of Parent/Guardian                                                                                            

Dated: