Active OOSH
Medical Management Form

Please ensure this form is filled out thoroughly, providing as much detail as possible along with the relevant action plan signed by your child's doctor.

Active OOSH Service *

Child's Details

Given Name *

Last name *

Child's date of birth *

Name of child's Doctor *

Contact number of child's doctor *

Emergency Contact Details

Parent 1 Name (first & last) *

Parent 1 contact number *

Emergency Contact Name *

Emergency Contact number *

Known condition details

Child's known condition *

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

Please provide a clear explanation of your child's known condition *

Please select any circumstances or activities that may trigger the onset of symptoms for your child. *

Exposure to allergens such as pollen or dustBeing around smoke from bushfires or traffic pollutionExposure to irritants E.G. cleaning products, perfumes or aerosolsWhen participating in physical activityWhen unwellOn excursionsExposure to cold air and windOther

Please select any circumstances or activities that may trigger the onset of symptoms for your child. *

Please list all potential circumstances or activities that may trigger the onset of symptoms for your child. *

Other potential triggers for the onset of symptoms, or more information about those you've ticked above

Please select any potential signs, symptoms or reactions your child may develop. *

Other potential signs, symptoms or reactions your child may develop, or more information about those you've ticked above

Please list all of the potential signs, symptoms or reactions your child may develop. *

What preventative strategies are effective in reducing or mitigating risks associated with this condition? *

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

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

Does your child require dietary modifications with this condition? *

YesNo

Please specify your child's dietary requirements *

Will your child require specific strategies or resources to support the management of their behaviour or emotions while at Active OOSH? *

YesNo

Please specify suggested strategies *

Medication at OOSH

Will your child require reliever medication to be administered by Active OOSH staff? *

NoNo - My child can self-administer and their puffer will be stored in their bagYes - My child's puffer will be stored at OOSH

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 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's Anaphylaxis Plan state any additional medication other than an EpiPen? *

YesNo

I understand that the medication specified on my child's Anaphylaxis Plan is required onsite at Active OOSH, along with my child's EpiPen. *

I hereby take full responsibility for providing Active OOSH with this in-date medication, clearly labelled with a pharmacy-printed label. *

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

No - My child is not medicatedNo - My child's medication is administered at home onlyYes - Regular medicationYes - On an as-required basis (e.g. allergy medication)

Remember to account for medication requirements during Vacation Care as well as during Before/After School Care

Name of medication *

How often is the medication administered? *

Once dailyMultiple times per dayAs required

Dosage Amount *

Method of Administration *

Times OOSH will need to administer medication *

Time the medication will have last been administered *

Time the medication will next be administered *

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 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. *

Medical Plan details

All children who have anaphylaxis, asthma, epilepsy, servere allergies, diabetes or require medication to be administered at OOSH are required to have a Medical Managment Plan prepared and signed by a registered medical practitioner.

The plan describes symptoms and causes of the medical condition and provides clear instructions on how to manage the medical condition in the context of the OOSH service, including any required medications and administration instructions.

If you are unable to upload your child's current Medical Plan, please ensure you send it via email to Active OOSH as soon as possible (admin@activeooshnsw.com)

Upload Asthma Action Plan *

Browse

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 Anaphylaxis Action Plan *

Browse

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 Allergic Reactions Action Plan *

Browse

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. *

Please upload the relevant Medical Management Plan or Diagnosis Report

Browse

Please notify the service immediately if there are any changes to your child's medical condition, medication, ASCIA Plan or Medical Management Plan. *

Parent or carer full name (first & last) *

Parent or Carer SIgnature *

Clear

Date *

Save and Complete Later

Active OOSH Medical Management Form

Child's Details

Emergency Contact Details

Known condition details

Medication at OOSH

Medical Plan details

Save and Complete Later

Active OOSH
Medical Management Form