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03 Medical Conditionp65

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					                                                                                        OFFICE USE ONLY:

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                                                                                        Distributed to Teacher(s)
Kirinari Community School Inc
18 Trimmer Tce
Unley SA 5061

abn 83 215 967 673




Student Medical Condition
To be read in conjunction with information contained on the Registration Form

STUDENT

Surname


Other Names
                                       FIRST NAME                                           SECOND NAME



MEDICAL CONDITION
Please indicate the medical condition (please use a separate form for each condition):

           Allergy                      Asthma                      Blood Disorder                  Diabetes

           Dizziness                    Epilepsy                    Hearing                         Vision

           Education Needs              ADHD / ADD                  Other:


Please describe the condition (ie allergies to particular foods):




Please identify any medications for this condition:




Please describe any medical action the school may have to take and under what circumstances:




Please identify any medicines the school will need to have on campus and describe administration (if necessary):




Anything else we should know?




Should any emergency assistance be required, we will attempt to contact you and the emergency contact as nomi-
nated. If the doctor identified on the Registration Form is unavailable, the school will arrange alternative treatment. Par-
ents accept responsibility for all costs incurred.

SIGNATURE

Parent / Guardian                                                                        Date


                                                                                                /medical condition.p65 v1.0 (2007)

				
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Description: 03 Medical Conditionp65