Holiday Program BOOKING FORM

Transcription

1 Holiday Program BOOKING FORM January 2016 PRICES EFFECTIVE FROM 1 JANUARY 2016 RISK MANAGEMENT ASSESSMENT IS AVAILABLE AT OUR WEB SITE Please return by info@bathurstgoldfields.com.au OR FAX Enrolment Process: 1. Complete the attached enrolment form 2. Complete Allergy, Anaphylaxis or Asthmas forms (as applicable) 3. Complete payment for the program using one of the options below 4. Return medical forms, payment and enrolment form to the Bathurst Goldfields before Friday 11 th December or via info@bathurstgoldfields.com.au Once these steps are completed, you will receive confirmation of your enrolment and booking for of 4

2 DATE PERSONAL DETAILS Name of Child Age Date of Birth Year at School Address PARENT DETAILS Parent 1 Address Phone PARENT CONTACT DETAILS - 1 Name Address Phone Contact number during Holiday Program PARENT CONTACT DETAILS 2 EMERGENCY CONTACT Name Address Phone Contact number during Holiday Program 2 of 4

3 ARRIVAL AND DEPARTURE TIMES Arrival Time Departure Time Name of Parent/Guardian Dropping off Name of Parent/Guardian Picking Up BOOKING DAYS please tick MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY Pricing Daily cost of $70 per child or $360 for the full 5 day program FULL WEEK MEALS Does your child have any dietary requirements? YES NO Does your child have any allergies? YES NO If YES, please complete the attached Allergic reactions form attached. Meal (price is per head incl GST) Date Breakfast ( am) additional $ of 4

4 ACTIVITIES Please tick the activities your child would like to complete. Activity TICK Grow the Music Full Music Program Scientific Experiments Navigation and Orienteering Boot Camp (each morning) Art and Craft Various activities throughout the week Movie Making Cooking Gold Panning History in the Making Photography Please be aware activities may be dependent on weather and numbers. Payment Methods Direct Deposit to; Bathurst Goldfields BSB Account # Credit Card.../.../.../... Exp... /... 4 of 4

5 ACTION PLAN FOR Allergic Reactions Name: Date of birth: Photo Confirmed allergens: MILD TO MODERATE ALLERGIC REACTION Swelling of lips, face, eyes Hives or welts Tingling mouth Abdominal pain, vomiting (these are signs of anaphylaxis for insect allergy) ACTION FOR MILD TO MODERATE ALLERGIC REACTION For insect allergy, flick out sting if visible. Do not remove ticks. Stay with person and call for help. Give other medications (if prescribed)... Phone family/emergency contact. Family/emergency contact name(s): Mild to moderate allergic reactions may not always occur before anaphylaxis Watch for ANY ONE of the following signs of anaphylaxis Work Ph: Home Ph: Mobile Ph: Plan prepared by: Dr: I hereby authorise medications specified on this plan to be administered according to the plan. Signed: Date: Date of next review: Note: The ASCIA Action Plan for Allergic Reactions is for people with mild to moderate allergies, who need to avoid certain allergens. For people with severe allergies (and at risk of anaphylaxis) there are ASCIA Action Plans for Anaphylaxis, which include adrenaline autoinjector instructions. Instructions are also on the device label and at: ANAPHYLAXIS (SEVERE ALLERGIC REACTION) Difficult/noisy breathing Swelling of tongue Swelling/tightness in throat Difficulty talking and/or hoarse voice Wheeze or persistent cough Persistent dizziness or collapse Pale and floppy (young children) ACTION FOR ANAPHYLAXIS 1 Lay person flat. Do not allow them to stand or walk. If breathing is difficult allow them to sit. 2 Give adrenaline autoinjector if available. 3 Phone ambulance*: 000 (AU) or 111 (NZ). 4 Phone family/emergency contact. Commence CPR at any time if person is unresponsive and not breathing normally. *Medical observation in hospital for at least 4 hours is recommended after anaphylaxis. IF UNCERTAIN WHETHER IT IS ANAPHYLAXIS OR ASTHMA Give adrenaline autoinjector FIRST, then asthma reliever. If someone with known food or insect allergy suddenly develops severe asthma like symptoms, give adrenaline autoinjector FIRST, then asthma reliever. Asthma: Y N Medication: ASCIA This plan was developed as a medical document that can only be completed and signed by the patient's treating medical doctor and cannot be altered without their permission.

6 Name: Date of birth: ACTION PLAN FOR Anaphylaxis For use with EpiPen adrenaline autoinjectors MILD TO MODERATE ALLERGIC REACTION Swelling of lips, face, eyes Hives or welts Tingling mouth Abdominal pain, vomiting (these are signs of anaphylaxis for insect allergy) Photo ACTION FOR MILD TO MODERATE ALLERGIC REACTION For insect allergy, flick out sting if visible. Do not remove ticks. Stay with person and call for help. Locate EpiPen or EpiPen Jr adrenaline autoinjector. Give other medications (if prescribed)... Phone family/emergency contact. Confirmed allergens: Family/emergency contact name(s): Work Ph: Home Ph: Mobile Ph: Plan prepared by: Dr: I hereby authorise medications specified on this plan to be administered according to the plan. Signed: Date: Date of next review: How to give EpiPen Form fist around EpiPen and PULL OFF BLUE SAFETY RELEASE. PLACE ORANGE END against outer mid-thigh (with or without clothing). PUSH DOWN HARD until a click is heard or felt and hold in place for 10 seconds. REMOVE EpiPen. Massage injection site for 10 seconds. Instructions are also on the device label and at: Mild to moderate allergic reactions may not always occur before anaphylaxis Watch for ANY ONE of the following signs of anaphylaxis ANAPHYLAXIS (SEVERE ALLERGIC REACTION) Difficult/noisy breathing Swelling of tongue Swelling/tightness in throat Difficulty talking and/or hoarse voice Wheeze or persistent cough Persistent dizziness or collapse Pale and floppy (young children) ACTION FOR ANAPHYLAXIS 1 Lay person flat. Do not allow them to stand or walk. If breathing is difficult allow them to sit. 2 Give EpiPen or EpiPen Jr adrenaline autoinjector. 3 Phone ambulance*: 000 (AU) or 111 (NZ). 4 Phone family/emergency contact. 5 Further adrenaline doses may be given if no response after 5 minutes, if another adrenaline autoinjector is available. If in doubt, give adrenaline autoinjector Commence CPR at any time if person is unresponsive and not breathing normally. EpiPen is generally prescribed for adults and children over 5 years. EpiPen Jr is generally prescribed for children aged 1-5 years. *Medical observation in hospital for at least 4 hours is recommended after anaphylaxis. IF UNCERTAIN WHETHER IT IS ANAPHYLAXIS OR ASTHMA Give adrenaline autoinjector FIRST, then asthma reliever. If someone with known food or insect allergy suddenly develops severe asthma like symptoms, give adrenaline autoinjector FIRST, then asthma reliever. Asthma: Y N Medication: ASCIA This plan was developed as a medical document that can only be completed and signed by the patient's treating medical doctor and cannot be altered without their permission.

7 My Asthma Action Plan When my asthma is well controlled No regular wheeze, or cough or chest tightness at night time, on waking or during the day Able to take part in normal physical activity without wheeze, cough or chest tightness Need reliever medication less than three times a week (except if it is used before exercise) Peak Flow* above What should I do? Continue my usual treatment as follows: Preventer Reliever Combination Medication Always carry my reliever puffer When my asthma is GETTING WORSE At the first sign of worsening asthma symptoms associated with a cold Waking from sleep due to coughing, wheezing or chest tightness Using reliever puffer more than 3 times a week (not including before exercise) Peak Flow* between and What should I do? Increase my treatment as follows: See my doctor to talk about my asthma getting worse When my asthma is severe Need reliever puffer every 3 hours or more often Increasing wheezing, coughing, chest tightness Difficulty with normal activity Waking each night and most mornings with wheezing, coughing or chest tightness Feel that asthma is out of control Peak Flow* between and What should I do? Start oral prednisolone (or other steroid) and increase my treatment as follows: See my doctor for advice Dr name:...ph...signature... Parent/Carer... Ph... How to recognise life-threatening asthma Dial 000 for an ambulance and/or 112 from a mobile phone if you have any of the following danger signs: extreme difficulty breathing little or no improvement from reliever puffer lips turn blue and follow the Asthma First Aid Plan below while waiting for ambulance to arrive. A serious asthma attack is also indicated by: symptoms getting worse quickly severe shortness of breath or difficulty in speaking you are feeling frightened or panicked Peak Flow* below Should any of these occur, follow the Asthma First Aid Plan below. Asthma First Aid Plan 1 Sit upright and stay calm. 2 Take 4 separate puffs of a reliever puffer (one puff at a time) via a spacer device. Just use the puffer on its own if you don t have a spacer. Take 4 breaths from the spacer after each puff. 3 Wait 4 minutes. If there is no improvement, take another 4 puffs. 4 If little or no improvement CALL AN AMBULANCE IMMEDIATELY (DIAL 000 and/or 112 from mobile phone) and state that you are having an asthma attack. Keep taking 4 puffs every 4 4 minutes until until the the ambulance arrives. See your doctor immediately after a serious asthma attack. Name:... Date:... Best Peak Flow*:... Next Doctor s Appointment:... * Not recommended for children under 12 years

8 My Asthma Action Plan This written Asthma Action Plan will help you to manage your asthma. Your Asthma Action Plan should be displayed in a place where it can be seen by you and others who need to know. You may want to photocopy it. What happens in asthma? Asthma inflames the airways. During an asthma attack, the air passages (airways) of the lungs become inflamed, swollen and narrowed. Thick mucus may be produced and breathing becomes difficult. This leads to coughing, wheezing and shortness of breath. Asthma Triggers Common asthma triggers are house dust mite, pollens, animal fur, moulds, tobacco smoke, and cold air. It is unusual but some foods may trigger asthma attacks. Exercise is a common asthma trigger but can be well managed with pre-exercise medication and warm-up activities. My known asthma triggers are: Before exercise I need to warm up properly and take the following asthma medication: Useful telephone numbers Asthma Foundation for information and advice about asthma management My pharmacy:... How your preventer medicine helps Your preventer medicine reduces the redness and swelling in your airways and dries up the mucus. Preventers take time to work and need to be taken every day, even when you are well. Preventer medications are: Qvar (beclomethasone), Flixotide (fluticasone), Intal Forte CFC-Free (sodium cromoglycate), Pulmicort (budesonide), Singulair (montelukast) and Tilade CFC-Free (nedocromil). How your reliever medicine helps Your reliever medicine relaxes the muscles around the airways, making the airways wider and breathing easier. It works quickly to relieve asthma symptoms, so it is essential for asthma first aid. Reliever medications are: Airomir, Asmol, Epaq and Ventolin (all brands of salbutamol) and Bricanyl (terbutaline). How your symptom controller helps Symptom controllers can help people who still get symptoms even when they take regular preventer medicines. If you need a symptom controller, it should be taken with your preventer medication. It should not be taken instead of a preventer. Like your reliever medicine, your symptom controller helps widen the airways. But while your reliever works for around 4-6 hours, symptom controllers work for up to 12 hours at a time. However, they are not good for quick relief of symptoms so they should not be used for asthma first aid. Symptom controllers are: Foradile and Oxis (both brands of eformoterol), and Serevent (salmeterol). There are combination medications that combine a symptom controller and a preventer in one puffer. Combination medications are: Seretide (fluticasone and salmeterol) and Symbicort (budesonide and eformoterol). Your GP can advise you on the availability under the Pharmaceutical Benefits Scheme of the drugs mentioned above. My medications are Preventer Reliever Symptom Controller Combination Medication Other Comments reprinted November 2006