Student Health Form This form must be filled and completed by parents/legal guardian only. Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Student Name *FirstLastDate of Birth *Email *MEDICAL HISTORYPlease tick any of the following medical conditions if your child is currently suffering from: *AsthmaADHD or ADDMigrainesFits of any typeBack / Neck problemsDepression / AnxietyHepatitis A, B or CDizzy SpellsGlandular FeverAutism / Asperger'sEpilepsyHeart ConditionEating DisordersTuberculosisChronic Nose BleedsDiabetesColour BlindnessHIV or AIDSBedwettingSleep WalkingTravel sicknessOtherNonePlease state medical condition/s: *Is you child currently taking any medication? *Yes / NoNoYesIf yes, please state Health condition/s: *Name of medication/s: *Dosage and time/s to be taken: *Other treatment: *Has your child suffered a serious illness or injury in last 5 years? *Yes / NoNoYesIf yes, please provide details *Has your child had any surgery in last 5 years? *Yes / NoNoYesIf yes, please provide details *ALLEGIESIs your child allergic to any medication? *Yes / NoNoYesIf yes, please provide details *What treatment is required? *Does your child have any food allergies? *Yes / NoNoYesIf yes, please provide details *What treatment is required? *Does your child have any allergies to insect bites/stings? *Yes / NoNoYesIf yes, please provide details *What treatment is required? *Does your child have any other allergies? *Yes / NoNoYesIf yes, please provide details *What treatment is required? *OTHER HEALTH INFORMATIONDoes your child have a congenital condition? *Yes / NoNoYesIf yes, please provide details *Any other disabilities or conditions not mentioned above? *Yes / NoNoYesIf yes, please provide details *Homestay Student Health Declaration *I understand and agree with the discussion points belowI declare that I will disclose to Happy Homestay Adelaide (HHA) any medical condition that I might contract prior to or during my child’s stay at the homestay. Additionally, I agree to disclose any pre-existing medical or health condition of my child that may require ongoing or intermittent medical attention or that may affect the homestay family. I agree that if prescribed medication needs to be administered, a designated adult of host family will be assigned to do this. I will ensure that prescribed medication is clearly labelled, securely fastened and handed to the designated adult with instructions on its administration. I will inform the HHA as soon as possible of any changes to medical or other circumstances detailed here. I agree to my child receiving any emergency medical, dental, or surgical treatment, including anaesthetic or blood transfusion, as considered necessary by the medical authorities present. I confirm that homestay host and HHA are not responsible for any issues caused by inaccurate health-related conditions, and the student will be required to move out immediately if such conditions are revealed. In this event, the homestay fee is non-refundable, and arranging alternative accommodation will not be the responsibility of HHA. I agree and acknowledge that HHA may collect personal information including medical information as a result of homestay application and health form, being informed from the institution and/or staying at the homestay and acknowledge that this information will only be used for the arrangement of homestay, and medical service either directly or indirectly and no other purpose.Parent(Legal guardian) Name *FirstLastSignature of parent(Legal guardian) * Clear Signature Date *Submit This form must be filled and completed by parents/legal guardian only.
