Under the St John Ambulance Australia Management of Health Conditions Policy (Cadet/Youth Program), parents/guardians of members under the age of 18 years are required to inform St John of any health condition that affects their child’s enrolment or participation in the Program. Youth Details Given Name Surname Date of Birth Gender - None - Male Female Other Address Parent/Guardian Details Given Name Surname Phone Number Relationship Email Medical Information Has your child been diagnosed with any of the following? Epilepsy Yes No Hearing/Vision Impairment Yes No Respiratory problems (e.g. Asthma) Yes No Allergic rhinitis (Hay fever) Yes No Allergies (including anaphylaxis and hay fever) Yes No Migraines/headaches Yes No Conditions that affect behaviour (e.g., Autism, ADD, ADHD, ODD) Yes No Mental Health Concerns Yes No Learning difficulties Yes No Heart problems Yes No Diabetes Yes No Anxiety Yes No Do you have any further information about your child, either medical or behavioural, that you think we should know about? Declaration I declare that the information herein is true and correct. I acknowledge the requirement to provide St John NT with up-to-date and accurate information regarding my child's health including advising of any changes to my child's health condition, or any other condition that develops during their engagement with the Program. I confirm that I have read and agree to the above declaration Privacy Statement St John NT is committed to protecting your personal information. Any information contained in this form will only be used for legitimate purposes by St John NT members and staff. St John will take all reasonable steps to ensure that the information we hold about your child is secure, accurate and up-to-date. I confirm that I have read and understood the privacy statement Parent/Guardian Signature Sign above CAPTCHA This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
