TE AUTE COLLEGE

Student

First NameLast Name

Date of Birth

Date

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

NEXT OF KIN

First NameLast Name

Relationship

ParentGrandparentCaregiverOther

Phone number

Please enter a valid phone number.

EMERGENCY CONTACT

First NameLast Name

Relationship to Student:

ParentGrandparentCaregiverOther

Does your son/moko have any of the following:

If yes, please give details to any of the above:

Does your son/moko have any allergies? (food, insect stings, medications etc). If yes, please give details.

Does your son/moko have a serious illness or any other medical conditions:

Please give details of any regular medication your son/moko is taking (include Asthma Information)

Medication?

What is it for / Dosage / How often?

Medication?

What is it for / Dosage / How often?

Would you like the school nurse to contact you if your son/moko is unwell or needs to see a doctor?

YesNo

Do you consent to your son/moko having a Flu injection each year to prevent the Flu virus circulating through the classrooms and dorms?

YesNo

Our nurses work under standing orders which enables them to legally assess patients and administer medical treatment if required. If you agree for your son/moko to be able to get medical assistance at school please indicate below:

YesNo

Student and Parent Rights

Every provider must take action to inform Students/Parents of their rights (Health and Disability Code of Rights). You have the right to: respect, fair treatment, dignity and inderpendance, service of a proper standard, effective communication, full information, to make informed choices and give informed consent, and make complaints. For more information on the Code of Rights visit: www.govt.nz

Medical Consent

By signing I hereby understand my rights as a parent/caregiver and request that all medication be administered to my son/moko as described and directed throughout this form. I give permission for the exchange of information between his GP and the school nurse and I understand that I must supply the school with no more than a three month (1 school term) supply of medication (including Asthma Inhalers). If you choose for your son/moko to stay with their home town GP, and they get sick while at school with their home town GP, and they get sick while at school, the student will be taken to the Hastings Medical Centre as a casual and this will incur a casual fee. Alternatively they can be enrolled with our medical service - Hauora Heretaunga (for more information, see the school nurse). Sports injuries will be covered by ACC.

Parent/Caregiver Name

First NameLast Name

Signature

THANK YOU - YOU HAVE COMPLETED OUR HEALTH FORM. If your son/moko is immunised, can you please upload a copy of his record. This can come later if you do not have access to it.

TE AUTE COLLEGE ENROLMENT FORM

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