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Awesome Adventures - Medical Information Form

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					        Awesome Adventures - Application Form
The information provided from this form will help staff ensure that your teenager
benefits from his/her experience during the program. Please fill out the confidential
ENROLMENT section completely. Where there is a choice of answers, underline
those areas you feel apply to your son/daughter.

Please forward the completed forms to:
Hawthorn Aquatic & Leisure Centre                                        PLACE
Attention: Naomi Spruzen
Linda Crescent                                                          PICTURE
HAWTHORN 3122
Fax: 03 8862 9100                                                         HERE

Permission of Photograph

I……………………………….(parents/guardian) agree to give permission to use the above
photograph to be for identification purposes only.

Parent Signature…………………………………….. Date……………

                                 ENROLMENT FORM

Date:______________________________________________________

Name of son/daughter:________________________________________
Date of Birth:________________________________________________
Type of Disability:____________________________________________
Name of mother:_____________________________________________
Phone:(H)_____________(B)_____________(M)___________________
Address:___________________________________________________
Name of father:______________________________________________
Phone:(H)_____________(B)_____________(M)_____________
Address:___________________________________________________
Who is the custodial parent/guardian of your son/daughter? (If applicable)
__________________________________________________________

Who will be collecting your son/daughter?_________________________
Person to contact in an emergency (daytime):______________________
Name: (1)__________________________________________________
Relationship to participant: _____________________________________
Phone No:__________________________________________________
Name (2): ________________________________________________________
Relationship to the participant:________________________________________
Phone No:________________________________________________________

Family Doctor:______________________________Ph:____________________
Medicare Number:____________________________
Ambulance Subscriber No:___________________________________________

The following section will ask you to elaborate on your son/daughters
disability:_____________________________________I, the undersigned have read,
understood and approve of the following application, and in doing so agree that the
YMCA and it’s officers, staff and agents shall be released from, and shall not incur
any responsibility or liability for any accident or injury to the applicant, or for any
damage to or loss of property of the applicant. I further
authorize you to obtain medical/ambulance assistance in the case of accident or
emergency involving the applicant and I agree to bear any cost thereby incurred.

Signature _________________________________Date__________________
                      CONFIDENTIAL—INFORMATION SHEET

HEALTH AND SAFETY

Please briefly explain your son/daughter’s sense of road safety?
_____________________________________________________________________



Are there any special measures to be taken when crossing roads?
______________________________________________________________




RESTRICTIVE INTERVENTIONS/MEDICATION

What, if any medication is your son/daughter taking?
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________

Does your son/daughter require medication whilst on the actual program?

Yes/No

If so, please describe the dose and times to be given:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________

Is your son/daughter epileptic? Yes/No

Comments:
_____________________________________________________________________
_____________________________________________________________________

Are there any special safety requirements for your son/daughter that are not listed
within the restrictive intervention or compulsory treatment section?
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
PERSONAL MANAGEMENT

How is your son/daughter with going to the toilet? Please circle
Fully Independent
Will indicate need, but needs to be taken
Needs to be taken frequently
Reminder to wash hands only
Reminder to adjust clothing

Comments




For non verbal participant, how does he/she indicate if they need to go to the toilet?
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________

Are staff required for lifting/transfer of your child/children?
_____________________________________________________________________
_____________________________________________________________________

COMMUNICATION

Are there any strategies in communicating with your son/daughter? i.e Interaction
with other children?

_____________________________________________________________________
_________________________________________________________________


EATING
Describe any assistance your son/daughter needs with eating?
_____________________________________________________________________
____________________________________________________________________

Are there any foods which need to be avoided? ie. nuts Yes/No. Comments:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
ANIMALS
How does your son/daughter react to animals? Likes animals/Indifferent/Fears
animals/Is obsessive. Any other comments:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________

TRAVEL
Any special instructions when traveling? ie. travel sickness
_____________________________________________________________________
_____________________________________________________________________


How does you son/daughter interact with the other children?




Any other information you think may be helpful to us please provide below;
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________

Individual Program Plan (IPP)
Is there anything we can or should include in your son/daughters current IPP?

_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________

				
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