Parent/Guardian Name *

First Name

Last Name

Child's Name *

First Name

Last Name

Child's Gender *

Male

Female

Does your child have a medical condition/health concern that needs to be managed during the school day?

Select the appropriate box or if not mentioned please specify

Allergies

Asthma

Diabetes

Seizure disorder (e.g. epilepsy)]

Hearing impairment

Physical disability

Speech impairment

Visual impairment

Intellectual/learning impairment (e.g. dyslexia)

Acquired brain impairment

Mental health or behaviour issue (e.g. depression, ADHD)

Emergency Contact 2 *

Must be different to parent/guardian named above

First Name

Last Name