Nipper Health Information
Chiton Rocks Surf Life Saving Club
Name of Child
*
First Name
Last Name
Date of Birth
*
/
Day
/
Month
Year
2 digit day, 2 digit month, 4 digit year
MEDICAL CONDITIONS
Does your child have a medical or health condition?
*
Please Select
YES
NO
If “YES”, please give details of the medical/health condition:
Are you aware of any medical emergency which could occur?
*
Please Select
YES
NO
If “YES”, please give details, precautions to avoid emergency:
How to recognise emergency:
Emergency treatment required:
MEDICATION
Does your child take any prescribed medication (including inhalers)?
Please Select
YES
NO
If “Yes”, please give details:
Medication Name
Dose
When taken
How taken
Side effects
Note:
Any medication needed during sessions should be handed to an Instructor on arrival, with written notes of your child’s name, medication, dose, etc.
Parent/Guardian Signature:
*
*
Parent/Guardian First Name
Parent/Guardian Last Name
Submit
Should be Empty: