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

Parents/Guardians

Emergency contact name

Emergency contact phone

Please indicate if your child had any of these illnesses

Covid-19 Chicken Po Whooping Cough Rubella Tuberculosis Mumps Pneumonia Tonsillitis Frequent Colds

Please indicate if your child had any of these illnesses

Covid-19 Chicken Po Whooping Cough Rubella Tuberculosis Mumps Pneumonia Tonsillitis Frequent Colds Impaired vision Speech Difficulty Concentration Difficulty Behaviour Problems Other

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

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.