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Medical Consent form

Please ensure that all details are completed. These forms provide important information to be used on retreats/camps and on a daily basis.

Student's Name:*
If applicable, student's College Email (CEWA email)
Year Group
PCG
D.O.B*
MM slash DD slash YYYY
Parent's/Guardian's Full Name*
Address*
Suburb*
Postcode*
Telephone
Work
Mobile*
Medicare Number*
Ambulance Cover*
- Yes
- No
Health Fund*
PERSON TO BE CONTACTED WHEN PARENTS ARE UNAVAILABLE:
Primary Emergency Contact / Name*
Relationship to student*
Telephone – Primary Emergency Contact
Mobile – Primary Emergency Contact*
Secondary Emergency Contact / Name*
Relationship to student*
Telephone – Secondary Emergency Contact
Mobile – Secondary Emergency Contact*
Family Doctor
Medical Practice*
Telephone
PLEASE ACKNOWLEDGE IF YOUR CHILD SUFFERS FROM ANY OF THE FOLLOWING CONDITIONS: If so, the College requires INFORMATION regarding triggers, signs and symptoms of reaction and first aid medication. If your child has a medically approved Action Plan, please supply all relevant paperwork to be kept on file. Medications required (e.g. Epipen, Antihistamine) are to be held by the student on their person at all times.
Conditions 1
- ADD/ADHD
- Asthma
- Epilepsy
- Other (Please List):
Level of asthma severity*
- Mild
- Moderate
- Severe
Conditions 3
- Diabetes
- Migraines
- Dizzy Spells & Black Outs
- Heart Condition
Conditions 4
- Allergies to
- Anaphylaxis to
(An ASCIA Action Plan for Anaphylaxis is required. Please upload any supporting document to the file upload field below.)
Please select all applicable statements
- Student has a hearing aid
- Student is colour blind
- Student wears glasses or contact lenses
Other (Please List):
Allergies to
Level of allergies severity
- Mild
- Moderate
- Severe
Anaphylaxis to
Supporting Medical Documents
Drop files here or

Max. file size: 64 MB.
Any student required to take prescribed medication must provide the medication to staff in Student Reception where it will be securely stored. The student’s name, name of medication, the dosage and frequency must be clearly labelled. (All medications must be provided in their original packaging with a clearly visible label and expiry date. Blister packs of tablets that have been cut, will not be accepted.) It is the student’s responsibility to report to Student Reception where they will be required to self-administer the medication under the supervision of a staff member from Student Reception.

Parents are responsible for keeping the school up to date with any changes in medical status/information that occurs during the year.
IF YOUR CHILD REQUIRES ONGOING MEDICATION (INCLUDING VENTOLIN), PLEASE COMPLETE THE FOLLOWING:
Name of Medication
Treatment for
Dosage
Frequency
Expiry Date
MM slash DD slash YYYY
MEDICAL CONSENT (This box must be completed by the student’s parent/guardian.)
I authorise school staff to administer FIRST AID treatment to my child, contact an ambulance and seek appropriate medical attention as may be deemed necessary.*
- Yes
- No
Hidden
I consent to my child’s image being used in College-related marketing and advertising campaigns and materials including newspaper and paid social media advertising.
- Yes
- Yes, as long as they are not identified by name
- No
Hidden
I consent to my child’s image being used in school-related publications and collateral including website and Parent Hub articles, newsletters, College Prospectus and the College Annual.
- Yes
- Yes, as long as they are not identified by name
- No
Hidden
I consent to my child’s image being used as part of social media posts (excluding paid social media advertising).
- Yes
- Yes, as long as they are not identified by name
- No
Parent/Guardian Name*
Date*
DD slash MM slash YYYY
By checking this box I declare all information in this form to be true and accurate*
- By checking this box I declare all information in this form to be true and accurate
Privacy Policy Information La Salle College collects personal information in accordance with Catholic Education Western Australian Privacy Policy. The Policy is available to view online: https://www.cewa.edu.au/publication/cewa-statutory-privacy-policy/.
Phone
This field is for validation purposes and should be left unchanged.

+61 (8) 9449 0601
lasalle@lasalle.wa.edu.au

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