Student Immunisation Record Student information Family name:
Given names:
Date of birth:
Gender: Day
Month
Female
Male
Country of citizenship:
Year
Dates of immunisations Type
Date
Date
Date
Date
Diphtheria/Tetanus/ Whooping Cough Diphtheria/Tetanus Polio MMR Hib Rubella Typhoid Hepatitis A Hepatitis B
Statement I hereby undertake to inform ACG School Jakarta of any changes of these details. In the event that there is an accident and neither I nor my emergency contact can be notified, I authorise the School to initiate emergency medical procedures as it deems necessary in the best interest of my son/daughter. If my child has a mild fever or headache, I authorise a staff member to administer Panadol
Signature of parent/guardian
Day
Month
ACG School Jakarta T: (+62 21) 2978 0200 | F: (+62 21) 781 4827 | E: acgjkt@acgedu.com Jl Warung Jati Barat (Taman Margasatwa) No 19, Jati Padang, Pasar Minggu, South Jakarta 12540, Indonesia | jakarta.acgedu.com
Year
Yes
No