Contact info 1625 Bellarine Highway Wallington, Victoria 3221 Australia 03 5250 1788 manager@wallingtonpark.com 1625 Bellarine Highway Wallington, Victoria 3221 Australia 03 5250 1788 manager@wallingtonpark.com If you are a human and are seeing this field, please leave it blank. Name Phone Email Subject Message 1. Please tick the appropriate box if your child suffers from the following: Bed WettingSleepwalkingSoilingSeizuresDiabetesHeadachesVision ImpairmentHearing LossDizzy SpellsHeart ConditionBlackoutsHay feverAsthmaFears/PhobiasOther If Yes, please give details: 2. Does your child have any chronic illness, medical condition, or physical restriction? YES / NO 3. Please tick the box which best describes your child’s ability to swim: ExcellentGoodPoorNon Swimmer Further Comments: 4. Is this your child’s first trip away from home without you? YESNO 5. Please tick the appropriate box if you child has been diagnosed with any of the following: AutismTourette ’s syndromeADHDIntellectual DisabilityPhysical DisabilityODDMental Health ConditionAspergers SyndromeOther If Yes, please provide a Behaviour Management Plan and further details: 6. Please tick the appropriate box if your child needs assistance with any of the following: BedtimeToiletingHygieneMeal TimesShoweringOther If Yes, please give details: 10. All prescribed medication is the be provided in a pharmacy issues Blister Pack, Webster Pack, or Dossette Box, that is clearly labeled. If your child is on medication, please list below: Medication Name Dosage - Before B/Fast Dosage - B/Fast Dosage - Other times Dosage - Lunch Dosage - Other times Dosage - Dinner Dosage - Other times Dosage - Bedtime Further Comments and Side Effects: PARENT'S/GUARDIAN'S STATEMENT PARENT'S/ GUARDIAN'S SIGNATURE DATE
