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Lagere School De Zonnewijzer
Kleine Hemmenweg 2 Dorpsstraat 62 tel: 011 81 35 28
3520 Zonhoven 3520 Zonhoven fax:011 81 49 97
Email: secretariaat@dezonnewijzerzonhoven.be
Website: http://www.dezonnewijzerzonhoven.be
Medische fiche en toelating deelname zeeklas
van .....................................................................klas ..........
Adres: …………………………………………………………………………………………………………………………………
Geboorteplaats:………………………………………… Geboortedatum: …………………………………..
Telefoonnummer THUIS: ………………………….. WERK:………………………………………………….
GSM-nummer mama: ……………………………….. GSM-nummer papa: ………………………………
Naam en nummer van een ander familielid bereikbaar tijdens de ZEEklas:
…………………………………………………………………………………………………………………………………………
Naam en telefoonnummer van de huisdokter:
………………………………………………………………………………………………………………………………………..
Ondergetekende geeft toelating aan bovenvermeld kind om deel te nemen aan de ZEEklas van
10-14 oktober 2016 te Nieuwpoort: JA / NEE
Eventuele reden voor niet-deelname :
……………………………………………………………………………………………………………………………………………
Belangrijke gegevens:
 Zijn er ziekten te melden? (suikerziekte, huidaandoeningen, astma, epilepsie, hart,…)
……………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………
Welke behandeling of medicatie is daarvoor eventueel vereist? Aanvraag formulier door
dokter laten invullen en voor vertrek bezorgen aan klasleerkracht!
………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………
 Is uw kind allergisch voor bepaalde stoffen of geneesmiddelen ? JA / NEE
- Indien JA, welke? ………………………………………………………………………………………………………
Welke behandeling of medicatie is daarvoor eventueel vereist?
………………………………………………………………………………………………………………………………
 Werd uw kind gevaccineerd tegen klem (tetanus)? JA / NEE In welk jaar? ……
 Andere inlichtingen betreffende uw kind waarop u de aandacht wilt vestigen
(bv.geneesmiddelen, nachtmerries, slaapwandelen, bedplassen, …)
………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………
 Moet uw kind tijdens het verblijf aangepaste voeding krijgen?
 dieet : lactosedieet – darmsparend dieet – glutenvrij dieet - ……………………………………………
 vegetarische voeding
 Indien uw kind tijdens de ZEEKLAS zich verwondt, ergens pijn heeft, door een insect wordt
gestoken of iets dergelijks zal de school steeds een inschatting maken van de ernst van de situatie
en zo efficiënt mogelijk handelen. Mogelijk gebruik van EHBO-middelen staan in onderstaand tabel:
In elk ander geval zal de school een plaatselijke huisarts contacteren!
Voeg hierbij 2 kleefbriefjes van de mutualiteit.
De ISI+- of kids-ID of identiteitskaart en de eventuele medicijnen afgeven aan de leerkracht bij het
vertrek.
Datum ……………………………………… Handtekening(en) ouder(s),
EHBO-middelen Verstrekt in geval van
Algi-cool zalf Blauwe plekken, kneuzingen
Cediumspray Verwonding
Euceta Insectenbeten
Iso-betadine Verwonding

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Zeeklas

  • 1. Lagere School De Zonnewijzer Kleine Hemmenweg 2 Dorpsstraat 62 tel: 011 81 35 28 3520 Zonhoven 3520 Zonhoven fax:011 81 49 97 Email: secretariaat@dezonnewijzerzonhoven.be Website: http://www.dezonnewijzerzonhoven.be Medische fiche en toelating deelname zeeklas van .....................................................................klas .......... Adres: ………………………………………………………………………………………………………………………………… Geboorteplaats:………………………………………… Geboortedatum: ………………………………….. Telefoonnummer THUIS: ………………………….. WERK:…………………………………………………. GSM-nummer mama: ……………………………….. GSM-nummer papa: ……………………………… Naam en nummer van een ander familielid bereikbaar tijdens de ZEEklas: ………………………………………………………………………………………………………………………………………… Naam en telefoonnummer van de huisdokter: ……………………………………………………………………………………………………………………………………….. Ondergetekende geeft toelating aan bovenvermeld kind om deel te nemen aan de ZEEklas van 10-14 oktober 2016 te Nieuwpoort: JA / NEE Eventuele reden voor niet-deelname : …………………………………………………………………………………………………………………………………………… Belangrijke gegevens:  Zijn er ziekten te melden? (suikerziekte, huidaandoeningen, astma, epilepsie, hart,…) …………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………… Welke behandeling of medicatie is daarvoor eventueel vereist? Aanvraag formulier door dokter laten invullen en voor vertrek bezorgen aan klasleerkracht! ……………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………………
  • 2.  Is uw kind allergisch voor bepaalde stoffen of geneesmiddelen ? JA / NEE - Indien JA, welke? ……………………………………………………………………………………………………… Welke behandeling of medicatie is daarvoor eventueel vereist? ………………………………………………………………………………………………………………………………  Werd uw kind gevaccineerd tegen klem (tetanus)? JA / NEE In welk jaar? ……  Andere inlichtingen betreffende uw kind waarop u de aandacht wilt vestigen (bv.geneesmiddelen, nachtmerries, slaapwandelen, bedplassen, …) ……………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………………  Moet uw kind tijdens het verblijf aangepaste voeding krijgen?  dieet : lactosedieet – darmsparend dieet – glutenvrij dieet - ……………………………………………  vegetarische voeding  Indien uw kind tijdens de ZEEKLAS zich verwondt, ergens pijn heeft, door een insect wordt gestoken of iets dergelijks zal de school steeds een inschatting maken van de ernst van de situatie en zo efficiënt mogelijk handelen. Mogelijk gebruik van EHBO-middelen staan in onderstaand tabel: In elk ander geval zal de school een plaatselijke huisarts contacteren! Voeg hierbij 2 kleefbriefjes van de mutualiteit. De ISI+- of kids-ID of identiteitskaart en de eventuele medicijnen afgeven aan de leerkracht bij het vertrek. Datum ……………………………………… Handtekening(en) ouder(s), EHBO-middelen Verstrekt in geval van Algi-cool zalf Blauwe plekken, kneuzingen Cediumspray Verwonding Euceta Insectenbeten Iso-betadine Verwonding