Form SY061, Medical statement - Assistance for Isolated Children (AIC) Scheme Completed Form Examples and Samples

Patient: Lachlan James Miller. DOB: 14/05/2012. Student CRN: 442-890-123-K. Parent/Applicant: Mrs. Sarah Jane Miller, living at 12 Sunnyside Road, Wagga Wagga, NSW, 2650. Phone: 02 6921 5555. Mobile: 0400 123 456. 

Dr. Aris Thorne, Pediatric Specialist at Riverina Specialist Clinic (15 Medical Plaza, Wagga Wagga, 2650; Ph: 0269001122), provided the following assessment. Lachlan presents with a complex, severe chronic allergic condition requiring a strictly controlled environment that is currently unavailable at local government schools. Given his reaction thresholds, daily travel to school poses a significant risk to his health. 

My diagnosis is Anaphylaxis with severe hypersensitivity to environmental allergens. This is a permanent condition. Treatment involves constant vigilance and the availability of emergency intervention not currently facilitated at his local school. I recommend that the student be permitted to study from home to maintain his safety. This medical condition is clearly serious. I confirm I have read and agree to the declaration as of 12 January 2026. My registration number is MED0001234567. As a specialist in Pediatric Immunology, I believe any release of specific diagnostic logs in this report should be handled with care, but the general findings are necessary for his AIC application.