Jones Tuition - Camp anaphylactic form

Anaphylactic Reactions Consent Form

For the administration of medicine/treatment as discussed with the child’s parent or guardian.

Child's Name

Date of Birth

Has the child’s details changed since the original Jones Tuition booking? (E.g. new address, new doctor new contact details)

Yes

New details:

Information about the child's allergy and reactions.

The child has been identified as having a severe reaction to ;

Signs and symptoms of the above child’s reactions are;

About the Medication that may be required or administered.

Name/Type of Medication

Dose/Amount

Frequency/Times

Specific Instructions ;

In the case of a reaction, Jones Tuition staff will follow the instructions as provided by the parent/guardian in treating the child.

In the case of a severe reaction Jones Tuition staff will adhere to the accident procedure found in the Policies and Procedures Document.

I the Parent/ Guardian have provided the Jones Tuition staff with all of the necessary information required by them to deal with my child’s condition, the symptoms and the actions required in the event of my child suffering an allergic reaction.

It is my responsibility to provide and maintain the appropriate and up to date medication/treatment for my child.

I confirm that the above information is correct and give permission for Jones Tuition staff to administer the medication in the manner stated above.

Signed Parent/Guardian

Print Name

Date

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!