Medical form

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Student medical form

Health Insurance Company

First, middle name

Surname

Date of Birth

Place of Birth

Nationality

Gender*

Male Female

Other legal guardian 1

Other legal guardian 2

Emergency contact name

Emergency contact phone

Please indicate if your child had any of these illnesses*

Covid-19 Chicken Pox Whooping Cough Rubella Tuberculosis Mumps Pneumonia Tonsillitis Frequent Colds Other None

Please indicate if your child had any of these illnesses*

Covid-19 Chicken Pox Whooping Cough Rubella Tuberculosis Mumps Pneumonia Tonsillitis Frequent Colds Impaired vision Speech Difficulty Concentration Difficulty Behaviour Problems Other None

Other informations* Is your child currently under medical supervision or routinely receiving medication? If yes, please describe bellow.

Other information* Is there any reason for your child to have restricted physical activity? Of yes, please describe bellow

Other medical information

Immunization

Preschool and Year 1 (only)
Submit a photocopy of your child's immunization report, ensuring compliance with vaccination requirements.
For children under 3 years old seeking admission to preschool, a medical confirmation from a pediatrician
affirming their ability to attend the school.

Medical permission* I authorize the school to administer non-prescription medicine to my child as appropriate

Yes No

Medical permission* If you would like to be informed first, tick here

Yes No

Accident treatment permission

I understand all efforts will be made to contact parents and emergency contact/contacts and if neither are available
I hereby give permission for emergency measures to be initiated in case of accident or sudden illness. I certify that all
information given is correct and complete.

By submitting this form, I confirm that all information provided is accurate and complete. I understand that submission of this form is considered equivalent to my signature.