Medical & Emergency Information Form Please complete this form and return to ACG School Jakarta at the time of your application. Please notify the School of any temporary supervision arrangements for students whenever parents leave Jakarta. Please supply the information requested below. Careful disclosure of medical information assists the School to care for its students.
Student information Family name:
Given names:
Date of birth:
Gender: Day
Month
Female
Country of citizenship:
Male
Year
Nominated emergency contacts (persons in Jakarta known to the student - who are not parents) Contact one Name:
Relationship to student:
Home phone:
Mobile phone: Country
Area
Local number
Country
Area
Local number
Area
Local number
Contact two Name:
Relationship to student:
Home phone:
Mobile phone: Country
Area
Local number
Country
Languages spoken:
Information which may be crucial in an emergency Is the student currently on any medication?
Yes
Please list the name of any medication and frequency:
No
Known reactions to any medication: Allergies
Yes
Please state which:
No
Date of most recent Tetanus shot:
Wears glasses/contact lenses: Day
Month
Yes
No
Year
The following health conditions may be of concern: Please tick any that apply Asthma
Hearing difficulties
Orthopedic problems
Visual/spatial problems
Congenital anomalies
Frequent headaches
Post-operative condition
Others (specify)
Convulsions/epilepsy(seizures)
Heart problems
Rheumatic fever
Diabetes
Kidney/urinary infections
Skin problems
Recurring ear infections
Menstrual problems
Tuberculosis
Please comment on any ticked items:
Has your child ever had an operation?
Yes
No
Why and when?
Detail any limits on physical activity:
Required for admission:
Current Tuberculin Skin Test
BCG Inoculation Record within the past 5 years
TB skin test type:
Date: Day
Result:
Physical:
BCG Vaccination:
Month
Year