BETAR – ‫בית"ר‬ MACHANE JUNGLE SAFARI MEDICAL FORM Betar runs overnight camps lasting up to 14 days in Winter and Summer for children aged between 8 and 18. Every camp is tended to by a qualified First Aid Officer. It important that every Camper/Madrich attending camp has a current medical form completed. If the camper has a medical condition and/or takes regular medication, this form should also be signed by the camper’s usual doctor. A: Medical Details Medicare Number: Ambulance Subscriber: qNo qYes: #____________ Private Health Fund: q No qYes: Fund: __________________ #: ____________________________ B: Dietary Requirements & Allergies Dietary Requirements: qVegetarian qVegan qLactose Free qGluten Free qOther_____________ Allergies: Additional Comments: C: Medication Does the Camper take any regular medication? q No q Yes (please indicate below) Medication: Dosage: Frequency: Medication: Dosage: Frequency: Is the Camper capable of self medication? q Yes qNo (must be supervised) Can the Camper be given Paracetamol in case of pain or fever? q Yes (1 tab) q Yes (2 tabs) q No (detail) D: Medical History (Note Details Below) q Anemia q Asthma (attach action plan) q Diabetes q Epilepsy q q q q Hernia Kidney Disease Liver Disease Mental Illness q Gastric Disease q Operations q Heart Condition q Sleeping Disorder q Eating Disorder q Other Is the Camper Fully Immunized according to the NHMRC schedule? Date of Last Tetanus Injection: / / Does the Camper have an Aide at school? q Yes q No Does Camper have any challenging Behavior/Disabilities? Doctors Comments ( If Any): Doctors Signature: Date: / / Additional Comments: Parent/Guardian Signature: Date: / / For all enquiries, questions or concerns with this form, please call Natalie Zaltsberg on 0425 125 353 or AJ Rich on 0417 176 585. During camp this number is to be used only in emergencies.