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
Medical & Emergency Information Form (continued) Student health
Please tick the boxes which apply to the student applicant 1) Do they have trouble with speech?
Yes
No
7) Do they ever have fainting attacks, blackouts, dizzy spells, convulsions or fits of any kind?
Yes
No
2) Have they ever had educational or psychological testing?
Yes
No
8) Are they on a special diet?
Yes
No
3) Do they have a history of emotional/ behavioural problems?
Yes
No
9) Do they have any allergies?
Yes
No
4) Are they under a physician’s care for any reason?
Yes
No
10) Do they have any problems that limit their participation in physical activities?
Yes
No
5) Do they have eye trouble of any kind, squint/lazy eye/wear glasses?
Yes
No
11) Are there any other matters relating to their health?
Yes
No
6) Do they have frequent colds, catarrh, nose bleed, sore throats, cough, wheezing or breathlessness?
Yes
No
Yes
No
If you have answered yes to any of the above questions please add details here:
Do any other members of the family suffer from any of the health conditions previously listed? (Asthma, ezcema, epilepsy, diabetes, etc.)
If so please give details and relationship to the student:
Preferred medical clinic Clinic name: Phone:
Doctor’s name: Address:
Special educational needs Does the student now (or in the past) have any special eductional needs?
Yes
(e.g. school support/referral to an educational psychologist, doctor or specialist)
Phone:
No
If yes, please present relevant assessment documentation.
Address:
Medical costs All medical costs are incurred by the parents or guardians. Medical examinations conducted overseas are acceptable. However, these records must be current within one year of the date of this application.
Statement I hereby undertake to inform ACG School Jakarta of any changes to 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.
Parent/guardian’s signature
Day
Month
Year
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