Student Health Record

It is a condition of enrolment that a parent or guardian must complete and submit this record to Christ Church prior to a student starting or re-entering the School. Failure to do so will result in a student's enrolment being suspended. In the event of an emergency, the School will make every effort to contact you or your emergency contact. However, if such contact cannot be made, the School will organise essential medical and/or dental treatment. If necessary, ambulance transport will also be arranged by the School. Costs for these arrangements remain the responsibility of the parent.

Important! Do you have a copy of your son/ward's immunisation record ready to upload?

In order to continue past this point, you MUST have scanned and saved a PDF format of your son/ward's immunisation record.

I have the immunisation record:*

Yes
No

Immunisation record upload*

Please upload your son/ward's Immunisation Record here. Please ensure it is saved in PDF format before uploading.

No?

PLEASE DO NOT CONTINUE WITH THE SUBMISSION AT THIS TIME. ONCE YOU HAVE OBTAINED A COPY OF YOUR SON/WARD'S IMMUNISATION RECORD, PLEASE COME BACK.

BOARDING

Is your son a Boarder?*

Yes
No

Important! Medical Practitioner form for boarders

Before proceeding with this submission, please visit your son's/ward's doctor to complete the Medical Practitioner form. Please download the MEDICAL PRACTITIONER FORM to print and take with you. This form can only be completed by your son's/ward's doctor. Once completed, please scan and save in PDF format before uploading as part of this submission. Please note, provision of the medical practitioner's form is vital to the enrolment of your son/ward. Failure to complete the submission in its entirety will delay your son's/ward's entry into the School.

Completed Medical Practitioner form - upload here*

Please ensure your save the form in PDF format and upload here before submitting this form.

STUDENT DETAILS

Academic year of entry to the School*

Please select year of entry required using drop down boxes below (click on arrow)

If other, please select

Son/Ward Surname*

Son/Ward First name*

Son/Ward Date of birth*

Should Health Centre staff need to contact you as the parent, please indicate your best contact number below:*

EMERGENCY CONTACT (not parent)

In the case of an emergency, we will contact you in the first instance. Should we not be able to contact you, please nominate a responsible adult who resides in Perth and who can be reached in an emergency.

Emergency contact first name*

Emergency contact surname*

Emergency contact mobile phone number*

Emergency contact email*

Emergency contact relationship to student*

MEDICATIONS

Is your son currently taking any medications on a regular basis?*

Yes
No

Medication 1 name*

Medication 1 dosage*

Medication 2 name

Medication 2 dosage

Medication 3 name

Medication 3 dosage

ASTHMA

If your son's asthma is moderate or severe, we will require you to upload a copy of his Asthma Action Plan.

Does your son suffer with asthma?*

Yes
No

If yes*

Mild
Moderate
Severe

Upload Asthma Action Plan here*

Has your son been hospitalised as a result of an acute asthma attack?*

Yes
No

Date of last hospitalisation*

Preventative used:*

Reliever used:*

What triggers an attack? (eg. allergy, exercise, chest infection)*

ALLERGIES

Does your son suffer with any allergies?*

Yes
No

Type of allergy*

Medication
Food
Bee
Other

Reaction*

Treatment required*

Is your sons allergy?*

Mild
Moderate
Severe (Anaphalaxis)

Please indicate below which food/s your son is allergic too:*

Has your son been hospitalised as a result of an allergic reaction?*

Yes
No

If yes, last hospitalisation date*

Anaphylaxis Action Plan

Upload your sons Anaphylaxis Action Plan here. Please contact the Health Centre on 08) 9442 1700 as nursing staff will need to meet with you and your son before he enrols or returns to to the School.

MEDICAL HISTORY

Does your son have a surgical or medical condition including enuresis?*

Yes
No

Please provide full details:*

Does your son have any mental health issues?*

Yes
No

Please provide full details:*

Student's Medicare Number*

Student's position on Medicare card*

Medicare card expiry date*

Student's Health Care Number

Health card expiry date

Private Health Cover/Name of Fund

Private Health Fund card number*

Dental*

Is your son currently enrolled with the Department of Health School Dental Service?

Yes
No

Name of dental clinic*

INFECTIOUS CONDITIONS

If your son develops a contagious condition or other significant problem he will need to leave the boarding house. If you are unable to assist your son at such a time, your sons nominated Guardian will be contacted to collect and take care of him on your behalf.

GENERAL INFORMATION

Please indicate if your son:*

Is colour blind
Wears glasses or contact lenses
Wears a hearing aid
Wears dental braces (Boarders only)

If colour blind, has he been:*

Tested
Untested

Does he:*

Wear glasses
Contact lenses

Name of orthodontist*

Is there any additional information you feel the School should know about your son/ward's health?

Any questions?

Please contact the Health Centre (08) 9442 1700 or health@ccgs.wa.edu.au

PARENT/GUARDIAN CONSENT

Parental/Guardian consent:*

I DO give consent for the School Health Centre to administer over the counter medication to my son/ward as deemed necessary
I DO NOT give consent for the School Health Centre to administer over the counter medication to my son/ward as deemed necessary

By ticking this box I declare:*

I have provided all my son's/ward's significant current and past medical history, including his immunisation record. In addition to this, I agree to inform the Health Centre staff of any relevant changes to his health status as well as any alterations to his contact details
I confirm that all information provided is true and correct

Full name of person completing this consent:*

Date you are completing this consent:*

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