Active OOSH Medical Management Form

Active OOSH Service *

Child's name (first & last) *

Child's date of birth *

Child's address *

Street address *

Suburb *

State *

Postcode *

Parent 1 Name (first & last) *

Parent 1 contact number *

Parent 2 Name (first & last) *

Parent 2 contact number *

Name of child's Doctor *

Contact number of child's doctor *

Address of Child's Doctor *

Street address *

Suburb *

State *

Postcode *

If your child has more than one of these conditions (e.g. asthma and anaphylaxis), please complete a seperate form for each.

Child's medical condition or diagnosis *

Will your child require an inhaler and/or spacer with reliever medication to be kept at Active OOSH? *

YesNo

I hereby take full responsibility for providing Active OOSH with in-date reliever medication along with an inhaler (and spacer as required), clearly labelled with a pharmacy-printed label. *

I hereby take full responsibility for my child having their own in-date reliever medication and inhaler (and spacer as required) in their personal belongings when attending Active OOSH. *

I give permission for my child to self-administer their required reliever medication. I have made sure that my child is aware that they must notify an Active OOSH staff member if they self-administer reliever medication while in the care of Active OOSH. *

I hereby take full responsibility for providing Active OOSH with, and updating as required, an annual Asthma Action Plan completed by my child's doctor. *

Upload Asthma Action Plan

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If you are unable to upload your child's current Asthma Action Plan, please ensure you send it via email to your Active OOSH service as soon as possible.

What are potential triggers for your child to require reliever medication? *

What level of support and supervision is required for management of your child's condition? *

What signs or symptoms does your child usually display before requiring reliever medication or medical assistance? *

Using the Risk Matrix above, how would you rate the likelihood and impact of your child's condition? *

LowModerateHighExtreme

What preventative strategies are effective in reducing or minimising risks? *

Who would you identify as being required or responsible for minimising risks? *

Known allergens *

I hereby take full responsibility for providing Active OOSH with an in-date EpiPen, clearly labelled with a pharmacy-printed label. I acknowledge that my child's EpiPen will be kept at the Active OOSH service for as long as my child is enrolled, and it is my responsibility to provide a new EpiPen after use or expiration. *

Does your child require any other medication to be kept at Active OOSH alongside their EpiPen? *

YesNo

Please name the medication *

I hereby take full responsibility for providing Active OOSH with a supply of in-date medication named above, clearly labelled with a pharmacy-printed label. I acknowledge that this medication will be kept at the Active OOSH service for as long as my child is enroled, and it is my responsibility to provide new medication as required (e.g. expiration or no supply left)
*

I hereby take full responsibility for providing Active OOSH with, and updating as required, an annual ASCIA Action Plan for Anaphylaxis completed by my child's doctor. *

Upload Anaphylaxis Action Plan

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If you are unable to upload your child's current Anaphylaxis Action Plan, please ensure you send it via email to your Active OOSH service as soon as possible.

Does your child require dietary modifications? *

YesNo

Please specify your child's dietary requirements *

What are potential triggers for your child to require use of their EpiPen? *

What level of support and supervision is required for management of your child's condition? *

What signs or symptoms does your child usually display before requiring their EpiPen or further medical assistance? *

Using the Risk Matrix above, how would you rate the likelihood and impact of your child's condition? *

LowModerateHighExtreme

What preventative strategies are effective in reducing or minimising risks? *

Who would you identify as being required or responsible for minimising risks? *

Known allergens *

I hereby take full responsibility for providing Active OOSH with, and updating as required, an annual ASCIA Action Plan for Allergic Reactions completed by my child's doctor. *

Upload Allergic Reactions Action Plan

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If you are unable to upload your child's current Allergic Reactions Action Plan, please ensure you send it via email to your Active OOSH service as soon as possible.

Does your child require medication to be kept at Active OOSH to manage their allergy? *

YesNo

Please name the medication/s *

Does your child require dietary modifications? *

YesNo

Please specify your child's dietary requirements *

What are the potential triggers for your child to experience an allergic reaction? *

What level of support and supervision is required for management of your child's condition? *

What signs or symptoms does your child usually display before requiring medical assistance? *

Using the Risk Matrix above, how would you rate the likelihood and impact of your child's condition? *

LowModerateHighExtreme

What preventative strategies are effective in reducing or minimising risks? *

Who would you identify as being required or responsible for minimising risks? *

Known condition or diagnosis *

Please upload the relevant Medical Management Plan or Diagnosis Report

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If you are unable to upload your child's current Medical Management Plan or Diagnosis Report, please ensure you send it via email to your Active OOSH service as soon as possible.

Does your child require dietary modifications? *

YesNo

Please specify your child's dietary requirements *

Will your child require medication to be administered by staff at the Active OOSH service (either during Before School Care, After School Care and Vacation Care) *

YesNo

I hereby take full responsibility for providing Active OOSH with a supply of in-date medication named above, in a clearly labelled webster pack with a pharmacy-printed label. I acknowledge that this medication will be kept at the Active OOSH service for as long as my child is enroled, and it is my responsibility to provide new medication as required (e.g. expiration or no supply left) *

What are potential triggers that may lead to your child requiring assistance with management of this condition? *

What level of support and supervision is required for management of your child's condition? *

What signs or symptoms does your child usually display before requiring assistance? *

Using the Risk Matrix above, how would you rate the likelihood and impact of your child's condition? *

LowModerateHigh Extreme

What preventative strategies are effective in reducing or minimising risks? *

Who would you identify as being required or responsible for minimising risks? *

Will your child require specific strategies (e.g. for management of emotions or behaviours) to be put in place by staff at the Active OOSH Service? *

YesNo

Please describe the strategies that work well for your child. *

Will your child require medication to be administered at OOSH? *

NoNo - Puffer will stay in my child's bagYes - Puffer or EpiPen will remain at OOSHYes - Medication during the school termYes - Medication during school holidays

Name of medication *

Dosage Amount *

Method of Administration *

How often is the medication administered? *

Once dailyMultiple times per dayAs required

Time the medication was last administered *

Time the medication will next be administered *

Please explain the circumstances under which the medication should next be administered *

Please list all scheduled time(s) the service will be required to administer the medication *Please remember to include times for School Holidays, if your child will attend Vacation Care days

I give permission for an Active OOSH Educator with relevant qualifications to administer my child’s medication as described above. *

I agree to immediately inform the service of any changes that need to be made to this arrangement. *

Parent or carer full name (first & last) *

Parent or Carer SIgnature *

Clear

Date *

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