Te Aute College Health Form

TE AUTE COLLEGE HEALTH FORM
Mobile Primary Nursing Te Taiwhenua o Heretaunga (TToH) provides medical services to the students of Te Aute College (TAC). They support and manage their health and wellbeing for as long as the student is enrolled at TAC.
Please indicate:

BoarderDay Student
Student

First NameLast Name
Date of Birth
Address of Parent/Caregiver

Street Address

Street Address Line 2

CityProvince

Postal / Zip Code
Relationship to Student
Contact Number
Emergency Contact Person

First NameLast Name
Relationship to Student
Emergency Contact Number
In order to maintain our records and help us care for your son/moko in an illness/emergency situation, could you please answer the following questions:
Doctor's name
Phone Number
Address
Is your son/moko Immunised?

YesNo
Please attached proof of immunisation. You can request this from your Doctor.

Cancelof
Does your child/moko have any of the following:

DiabetesHeart problemsVision problemsHearing problemsEczema or Skin disordersHeadaches / MigrainesHayfever or SinusAsthmaNone of the above
If yes to any of the above, please give more details.
Does your son/moko have any allergies. If yes please give more detail. eg Food, insect stings, medication.
Does your son/moko have a serious illness or any other medical conditions? If yes, please give more detail.
Please give details of any regular medication your child is taking. (include Asthma information)
Medication
What for?
Dose
How often?
Medication
What for?
Dose
How often?
Would you like the nurse to contact you if your son/moko is unwell or needs to see a doctor? The nurse will contact you if it is serious.

YesNo
Do you consent to your son/moko having the Flu Injection each year to prevent the Flu virus circulating through the classrooms and dorms.

YesNo
Our nurses work under standing order 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:

YesNo
Student and Parent Rights

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 that I understand my rights as a parent/caregiver and request that all medication be administered to my son as described and directed throughout this form. I give permission for the exchange of information between my son/moko's 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, 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
Parent/Caregiver Signature

Clear
Should be Empty:

TE AUTE COLLEGE HEALTH FORM