Health and Pastoral Form

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Student's Full Name

Student's Year

Medical Contact Details

Doctor

Dentist

Current Medical Information

Immunisation – Has the student received all available vaccinations/immunisations?

Mobile dental clinic – I consent to the student accessing the mobile dental clinic.

Current Medical Conditions

Asthma

Diabetes

Epliespy

Hearing Loss

Impaired Vision

Rheumatic Fever

Regular Medication

If you ticked any of the medical conditions above, please provide details

Allergies

Food

Medication

Stings

Epipen Use

Other

If you ticked any of the allergies above, please provide details

Any Dietary Requirements (Lunches in School)

Administering Medication

Allow Paracetamol Yes No

I give permission for the School to administer this treatment if necessary. (e.g Mylanta, Topical creams, Cough Syrup). In some cases, it is necessary for medication to be given for such things as stings/bites, abrasions, cuts, indigestion and cold etc. Yes No

IN CASE OF ACCIDENT OR EMERGENCY In case of a serious accident or emergency, an Ambulance will be called. A parent/guardian will also be called so please always ensure that the school has your current contact details. In case of an accident or emergency and the school cannot contact you or if the accident is serious the school may: • Transport my daughter to an Accident and Emergency clinic for treatment • Call an Ambulance if hospitalisation is required • Administer EPI pen, antihistamine or any prescription medication you have labelled and supplied as the caregiver for your student (together with the consent form) • Use Ventolin Inhaler in an asthma emergency, if own medicine is unavailable • Use our defibrillator in the event of a student suffering cardiac arrest. I give permission for Rotorua Girls’ High School to make such arrangements as are necessary including those listed, in case of an accident or emergency for the treatment of my daughter and agree to meet any cost incurred. Yes No

Mental Health and Wellbeing

Does the student suffer from any other medical condition or disability? (ie: anxiety, depression etc)

Any personal, home or social circumstances which will assist in understanding the student?

Support Agency

Case Worker

Learning & Behavioural Support

At Rotorua Girls' High School, we provide tailored support for students with diverse learning and behavioural needs. When enrolling your child, please list any specific needs so we can ensure they receive the individual attention and resources necessary to thrive academically and personally. Has your son/daughter been diagnosed with any learning or behavioural needs?

If yes, please select one of the following:

If other, please state here:

What support has your daughter had, and what support does she require?

Gifted and Talented

Has your daughter been excelled in any area of her learning? If so, please provide more details.

Special Interests

Please record the student’s academic, cultural, service and sporting interest(s) and significant achievement(s) (such as membership of a school or representative team) and awards.

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