Confidential
Methodist Ladies’ College
Medical Information
Student Name: _____________________________________________________________
Medicare Number: ___________________________________________________________
Name of Private Health Fund: __________________________________________________
Membership No: __________________________________________________
Family Doctor:
Name: _____________________________________________________________________
Address: ___________________________________________________________________
Phone: _____________________________________________________________________

Past Illness (If your daughter has had any of the following please tick)
Allergies
Asthma
Diabetes
Ear Ache
Mumps
Head Injury
Bronchitis
ADD
Depression
Hepatitis A/B
Headache
Epilepsy
Kidney Disease
Nose Bleeds
Back Injury
Glandular Fever
Meningitis
ADHD
Heart Disease
Discharging Ears
Fits
Hepatitis B Carrier
Hepatitis
Chickenpox
Measles
Rheumatic fever
Travel sickness
Acne
Any other major illness
If relevant, please comment further on the above, including severity.
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MLC is committed to respecting the privacy of individuals. Personal and health information collected on this form is collected,
held, used, corrected, disposed of or transferred in accordance with the National Privacy Principles and Privacy Act 1988 as
amended.
Please give dates when the following vaccinations were last given:
Vaccine
Tetanus
Diphtheria
Flu
Cholera
Hepatitis A
Meningitis C
Whooping Cough (Pertussis)
Date
Vaccine
Polio
Measles
Typhoid
Yellow Fever
BCG (tuberculosis)
Rubella (German measles)
Date
Current medical condition or recent illness:
Please comment on duration and severity of illness.
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Details of medication:
Does your daughter take regular medication? Yes/No
Name of medication: ________________________________________________________
Purpose of medication: _______________________________________________________
Dosage of medication required: ________________________________________________
When medication is to be taken: _______________________________________________
My daughter can administer this medication to herself: Yes
No
Please indicate if your daughter will be carrying her own medication:
Yes
No
Medication taken by your daughter in the event of an incident.
Please give details of medication and how it is administered. Information on treatment and
management of allergies and asthma (including type & triggers) is particularly important.
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MLC is committed to respecting the privacy of individuals. Personal and health information collected on this form is collected,
held, used, corrected, disposed of or transferred in accordance with the National Privacy Principles and Privacy Act 1988 as
amended.
Special Dietary Requirements:
__________________________________________________________________________________
__________________________________________________________________________________
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Additional Information:
Social issues e.g. homesickness, shyness; illness of other family member
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In the event of an emergency, the tour leader and/or College will make every attempt to contact a parent
of guardian in the first instance. If however such a contact cannot be made, the Tour Leader/College
will arrange for medical treatment and/or dental treatment or ambulance transport when this is
considered necessary.
I give permission for my daughter to be taken to a medical practitioner if deemed necessary by a tour
leader.
In the event of an emergency, if I cannot be contacted, I give permission for the Tour Leader to decide,
after consultation with Medical practitioners, on the type of any medical attention that my daughter may
require.
If my daughter is ill or requires hospitalisation for an extended period, I agree to travel to resume
responsibility for my daughter’s well being.
Name of Parent and/or Legal Guardian: ______________________________________________
Signature of Parent and/or Legal Guardian: ___________________________________________
Date: ___________________________
Page 3 of 3
MLC is committed to respecting the privacy of individuals. Personal and health information collected on this form is collected,
held, used, corrected, disposed of or transferred in accordance with the National Privacy Principles and Privacy Act 1988 as
amended.