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Home
Services
Therapy
Occupational Therapy
Clinical Psychology
Behaviour Support Services
Somatic Movement Therapy
Therapy Intensive Session Blocks
Group Therapy Programs
Creative Minds
Sense Rugby
Move and Mingle
Pre Kindy Group
Parent Workshops and Groups
Therapy Camps
Adventure Camps
Boys Camps
Camp Confidence
Girls Camps
East Kimberley Clinic
Functional Assessments
Therapy Intensive Session Blocks
Events
Resources
For Teachers and Parents
For Therapists and Students
Therapy Camp Supports
For Police and First Responders
Fees and Rebates
NDIS Funding
Home
Services
Therapy
Occupational Therapy
Clinical Psychology
Behaviour Support Services
Somatic Movement Therapy
Therapy Intensive Session Blocks
Group Therapy Programs
Creative Minds
Sense Rugby
Move and Mingle
Pre Kindy Group
Parent Workshops and Groups
Therapy Camps
Adventure Camps
Boys Camps
Camp Confidence
Girls Camps
East Kimberley Clinic
Functional Assessments
Therapy Intensive Session Blocks
Events
Resources
For Teachers and Parents
For Therapists and Students
Therapy Camp Supports
For Police and First Responders
Fees and Rebates
NDIS Funding
Home
Services
Therapy
Occupational Therapy
Clinical Psychology
Behaviour Support Services
Somatic Movement Therapy
Therapy Intensive Session Blocks
Group Therapy Programs
Creative Minds
Sense Rugby
Move and Mingle
Pre Kindy Group
Parent Workshops and Groups
Therapy Camps
Adventure Camps
Boys Camps
Camp Confidence
Girls Camps
East Kimberley Clinic
Functional Assessments
Therapy Intensive Session Blocks
Events
Resources
For Teachers and Parents
For Therapists and Students
Therapy Camp Supports
For Police and First Responders
Fees and Rebates
NDIS Funding
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Medication and First Aid Camper Form
Medication and First Aid Camper Form
Date form completed:
*
Day
Month
Year
Child’s Full Name:
*
Date of Birth
*
DD slash MM slash YYYY
Primary Emergency Contact Details
Name:
*
Contact Number:
*
Email
*
Secondary Emergency Contact Details
Name:
Contact Number:
Email
Medical Conditions and Diagnosis
Does your child experience Asthma?
*
Yes
No
If yes, please attach action plan here
*
Max. file size: 128 MB.
Does your child experience heart problems?
*
Yes
No
Please provide details here
*
Does your child experience seizures?
*
Yes
No
If yes, please attach action plan here
*
Max. file size: 128 MB.
Allergies
Allergy
Reaction
Treatment
If your child has any allergies please fill in the table
For any anaphylaxis reactions, please attach your child’s action plan here:
Max. file size: 128 MB.
Does your child have any other existing diagnosis or medical conditions?
*
Yes
No
If yes, please provide details:
Dietary Needs
Does your child currently have or have a history of dysphagia?
*
Yes
No
If you answered yes to the above question, please attach a meal time/management plan.
*
Max. file size: 128 MB.
Does your child have any dietary needs?
*
Yes
No
If yes, please describe:
Health Care Information
Doctors Name and Contact:
*
Ambulance Cover?
*
Yes
No
Do you give permission for us to call and ambulance on behalf of your child?
*
Yes
No
Do you give us permission to take your child to seek urgent medical attention from an Emergency Department or Urgent Care GP?
*
Yes
No
Mental Health
Does your child have a mental health condition such as anxiety, depression, bipolar, personality disorder, OCD etc?
*
Yes
No
If yes, please provide details here
Has your child in the past 6 months attempted suicide or self harm?
*
Yes
No
If yes, please provide details here:
Medication Summary
Medication schedule: Please add in your child’s medication, supplements, vitamins, minerals- anything that they will be taking on camp into the below timetable. Camp staff will then sign off after each event. For PRN and medications not considered to be for your child’s diagnosis, it is an NDIS requirement that if we give this medication on camp, we must report this to the NDIA commission as a restrictive practice. If you think your child will need to take a medication such as this, please contact us ASAP to arrange a plan.Please note that all medications and supplements in capsule or tablet form are required to be packaged in a blister pack. If they are not in a blister pack, we are unable to give these on camp. Please see the camp welcome pack for further information or contact us for any other queries
Medication summary
Medication
Dosage
Frequency
Name of doctor prescribing
Notes
Please include ALL medications, natural medications etc
Please upload a copy of your child's Positive Behaviour Support Plan if they have one here:
Max. file size: 128 MB.
Therapy Assistance Dogs- Camp Confidence and Camp Out Only
Please select which of the following apply for your child:
Is fearful of dogs
Has allergies relating to dogs
Is aggressive towards animals
Enjoys being around dogs
Other (please provide details below)
If your child is fearful, has allergies and/or is aggressive towards animals please provide details here. Please also provide details if you selected other.
Consent and Agreement
*
Select All
I have read and agree to Calm and Connected's Terms of Service https://calmandconnected.com.au/termsofservice/
If assistance is called on your child's behalf in the event of a medical emergency, you agree that they are permitted to go with the paramedics and a camp support staff member in the ambulance to the hospital. We will do our best to notify the child's primary contact as soon as reasonably possible.
I agree to voluntarily give permission for my child's participation in the camp, knowing that there are risks involved. I am aware and accept that some children – including mine – may experience strong physical and emotional reactions, and engage in unpredictable behaviour. Calm and Connected staff do all that they can to create a safe environment, and it is important that parents assist by being honest about my child's needs and abilities. Calm and Connected reserve the right to deny participation in the camp or any related activities at any time to children demonstrating behaviour that may result in injury to themselves or others. However, Calm and Connected are entitled to rely on the information given by caregivers when enrolling their child in the camp, and have no duty to deny participation in any activity. Failure to deny participation will not give rise to any claim for negligence.
I have read and agree to the policies and information outlined in the Camp Welcome Pack emailed to me, e.g. policies and processes including medication; the camp cancellation policy; process for times where children head home from camp early
I consent and agree to my child working with a training therapy dog on camp? Dogs go between groups throughout camp to support campers to regulate, and learn. Please let us know if you have any questions or concerns.
I agree to pick my child up early from camp if they have run onto a nearby busy road,, seriously harmed another support/camper or frequently becomes aggressive (physical/verbally/emotionally)
X
X
