Insert photo of student

Individual Health Care Plan

Study Tours

School Strathfield South High School

Student name Nadila nanda azzahra ruray

Date of birth 28 09 2002

Insurance Company - Number: -

Health condition/s healthy

If anaphylaxis, list the Dash allergy,cold allergy,food allergy

confirmed allergies

Impact of any of the Itchy

conditions (as mentioned
above) on the student at
school

Medication/s at school Obat alergi

Medication supply, racutane

storage and replacement.
For anaphylaxis this will
include the adrenaline
autoinjector

Parent/Carer contacts: Parent/Carer information (1)

First name ibrahim

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 Surname ruray

Relationship to child Biological father

Address Jln am kamarudin no 115 salero ternate

Home phone -

Work phone 085340280853

Mobile phone 08124751981

Parent/Carer information (2)

First name Sri muchrainy

Surname suro

Relationship to child Biological mother

Address Jln am kamarudin no 115 salero ternate

Home phone -

Work phone 085340280853

Mobile phone: 08124751981

Sri Indah
Emergency contacts (if First name
parent/carer unavailable)
Surname Permata

Relationship to child Carer

Address 87/68 Village Drive, Breakfast Point, NSW 2137

Home phone

Work phone +61 2 8757 3383

Mobile phone +61 438 608 022

Signature of Parent/Carer:
Date

Signature of Agent:
Date

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