STUDENT MEDICAL INFORMATION AND AUTHORISATION FORM
SAMPLE ONLY – NOT TO BE COMPLETED AT THE TIME OF APPLICATION
This is a sample of the medical form which will be supplied to winners of The Premier’s Anzac Prize 2016 and their parents. The
winners and their parents will be required to complete and sign this form, or a form similar to it, upon the request of the
Department of Education and Training (the Department). The Department may need to update this form before that time, or ask
additional medical questions before and on the tour. However the below form is a solid indication of what will be required.
Please carefully consider the Product Disclosure Statement, Policy Wording and Financial Services Guide provided
by GoSafe Travel Insurance: www.gosafetravelinsurance.com.au/pdses/GoSafe_pds_v1_Groups.pdf in particular
the information about pre-existing medical conditions, what the policy covers and what is not covered. The
Department will cover the cost of the travel insurance for the tour, including the additional premium required for
covering a pre-existing condition, where applicable. Please note some pre-existing medical conditions are not
covered. If you are unsure about anything in the information provided by GoSafe Travel Insurance please contact
them directly for clarification. You will be required to inform the Department, below, about any pre-existing
medical conditions.
Privacy Notice
This information is being collected for the purpose of organising, planning and supervising The Premier’s Anzac Prize 2016 tour.
Departmental supervising staff and teacher chaperones are responsible for the health and safety of students while they are travelling as part
of The Premier’s Anzac Prize 2016 (‘the tour’). Departmental supervising staff and teacher chaperones will be responsible for obtaining
medical treatment for students in the event it is required. Information you provide will be used to ensure that the students who will be
travelling overseas can safely participate in the planned itinerary, that any medical conditions can be appropriately accommodated, for the
purpose of arranging travel insurance and to ensure the Department and chaperones have all the information necessary to assist them to
discharge their duty of care to the student. The information may be disclosed to insurance organisations for the purpose of arranging travel
insurance. This information will be given to chaperones and may be provided to medical professionals in the event the student requires
medical attention on the tour or while in the care of the Department or a chaperone.
The information will not be used or disclosed for any other purpose without your consent unless the use or disclosure is required or
authorised by law. If you have any questions or concerns about the collection, storage, use or disclosure of the information, please contact
the Project Officer on 3513 5747.
Student and contact details
Student name:
School:
Emergency contact 1:
(next of kin)
Relationship:
Home phone:
Work phone:
Mobile:
24/7 contact number required
Email:
Emergency contact 2:
Relationship:
1
Home phone:
Work phone:
Mobile:
24/7 contact number required
Email:
Student’s doctor details
Name of doctor:
Phone:
Name of medical practice:
Address:
Email:
Medical specialist details (if applicable)
Name of doctor:
Phone:
Address:
Email:
It is important to answer the following four questions and provide as much information as possible.
Please consider the information provided by GoSafe Travel Insurance and advise:
1. Does the student have a pre-existing medical condition:
Yes
No
If Yes:
Please provide details of the condition, including severity,
treatment and any medication taken for the condition. For
severe medical conditions please attach an Emergency
Action Plan (the Department may request further details,
where necessary):
Please state if the student has been hospitalised
[including Day Surgery or Emergency Department
attendance] for that condition in the past 24 months:
Yes
No
If yes, please provide details
Is this a condition for which there is no cover for medical
expenses, cancellation costs or additional expenses
arising from or related to these particular conditions?
Yes
No
Is this a condition for which there is no cover whatsoever?
Yes
No
Is this a condition for which you can pay an additional
premium in order to cover events arising from this
condition?
Yes
No
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2.
Has the student been diagnosed with any medical condition, not listed above, that a medical practitioner
should be aware of if medical treatment is required (including allergies to medication)?
Yes
No
If yes, please provide details (e.g. severity, medication, special care required):
3.
Please list any conditions or health issues, not listed above, that the chaperones should be aware of while
they are responsible for the health, safety and welfare of the student (for example, if the student suffers from
travel sickness, sleep walking, phobias, food intolerance):
4.
Please provide any updated information about special medical requirements (refer to your answer to question
7 in Part A of the student application pack):
Medication
Prescribed medication:
Please give details of any prescribed medication being taken by your child/which will be taken with your child on the
tour — include dosage, frequency and any doctor’s instructions:
Non-prescribed medication:
Please give details of any non-prescribed medication being taken by your child/which will be taken with your child
on the tour (for example: paracetamol, travel sickness tablets, diarrhoea tablets, hay fever/allergy tablets, throat
lozenges, vitamins):
Please note some countries have restrictions on medications able to be brought into the country. Please confirm
the medication you intend to bring is allowable for Turkey, Belgium, France and Singapore.
Administration of medication
All medications must be labelled with the student’s name and kept with the student at all times during the tour.
Prior to departure, clear written instructions with respect to prescribed medication (and non-prescribed medication,
if necessary) must be handed to the supervising staff or chaperone, including dosage to be taken, specific storage
conditions, time to be taken and details of administration (for example, to be taken with food). It will be the
responsibility of the student to keep his/her own medications, to store securely and appropriately and administer as
required. All medication must be supplied in original packaging. In the case of prescribed medication, the
medication must be supplied with a doctor’s note confirming the prescription and necessity for a particular condition.
Vaccinations
The Department recommends all successful applicants obtain medical advice about vaccinations for travel to
Turkey, Belgium and France (noting there will be a stopover in Singapore). Please indicate whether your child has
received any vaccinations for this tour by circling A or B below. If you have circled A, please provide the names and
dates of vaccinations received.
A.
My child has received the following vaccinations which medical professionals have advised me are
recommended or necessary for this tour:
Name of Vaccination
Date of Vaccination
OR
B.
I have decided NOT to obtain any vaccinations for my child for this tour.
Last anti-tetanus injection date: ___/___/___.
Has your child been immunised against Hepatitis B?
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Yes
No
Authorisation for medical treatment and acceptance of liability for medical costs
The Department, supervising staff and teacher chaperones are responsible for the health, safety and welfare of
students while they on the tour and while they are in our care. If the student becomes ill or has an accident, the
supervising staff or chaperone will generally contact the student’s emergency contact immediately, in advance of
treatment being sought. However this will not necessarily happen:

for minor illness or injury;

in the event of an emergency where immediate action is required;

if the parent or emergency contact cannot be reached;

it is impractical to contact the emergency contact before treatment is sought.
The health, safety and welfare of all students on the tour are the overriding priorities of the Department, supervising
staff and chaperones.
I hereby authorise any of the supervising staff and/or chaperones to:

obtain, on my child’s behalf, such medical assistance my child may require in the event of an accident or
illness;

consent to my child receiving any medical or surgical attention deemed necessary by a medical practitioner;

administer such first aid as the supervising staff or chaperone considers to be reasonably necessary;

administer or assist my child to administer their medication referred to above, in the event of an emergency
situation.
I accept liability for all costs incurred in obtaining such medical treatment, which are not covered by GoSafe Travel
Insurance (including any excess payable under the travel insurance policy) and undertake to reimburse the
Department the full amount of any costs incurred on my child’s behalf.
Declaration

I hereby declare that the foregoing medical information is true and correct and includes all relevant
information.

I have read and understood the privacy notice, above.

I have read and understood the Product Disclosure Statement, Policy Wording and Financial Services Guide
provided by GoSafe Travel Insurance.
_____________________________________
Student Signature
____________________
Date
_____________________________________
Signature of Parent 1
____________________
Date
_____________________________________
Signature of Parent 2
____________________
Date
This form must be signed and returned via email to: internationalservices@dete.qld.gov.au no later than (date).
Please photocopy this form for your records. You are required to keep the Department informed of any changes to
information you have supplied.
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