STUDENT MEDICAL INFORMATION JOHN F. KENNEDY INTERNATIONAL SCHOOL Please print or type clearly. 1. Name of Student: _____________________________________ Sex: Date of Birth: ____________________ Class: ___________Nationality: 2. Please give any medical information that is relevant to your child’s full participation in the school program: _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ 3. Phone numbers / Email address to contact in case of emergency (parents/home, etc.): __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ 4. Indicate previous illnesses of child with approximate dates (day/month/year): Measles Mumps Chicken Pox H1N1 Flu Bronchitis Diabetes Rheumatic Fever Appendicitis Epilepsy Tonsilitis Asthma Other: ___________________________________________________________________________ 5. Allergies and Sensitivities: (Please check and explain below.) Insect Bites ☐ Medication ☐ Hayfever ☐ Other: ____________________________________________________________________________ __________________________________________________________________________________ 6. Has your child been under prolonged medical or psychological care at any time? If so, please specify. _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ 7. Does your child require any regular medication or other special measures to be taken with regards to health? Yes ☐ No ☐ If yes, give details: ________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ 8. A. Vaccinations: Please give exact dates (day/month/year). Vaccine Date Given Date Due Polio-Salk Polio-Sabin DTP Measles 9. Vaccine Date Given Date Due Rubella Mumps Tetanus H1N1 Has the above-named child suffered any illnesses or accidents or developed any allergies during the vacation? Please explain. __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ 10. Health Insurance’s Company: ______________________________________________________ 11. Policy Number: ___________________________________________________________________ Please provide the school with a copy of the medical insurance card which covers my child/children of all medical and accidents during their school term. 12. Doctor’s name, address and phone number: __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ 13. Should my child be injured or become ill while attending the John F. Kennedy School, I expect the school authorities to see that he/she is attended to by qualified medical or dental practitioners, and I authorise the school to act on my behalf in arranging whatever treatment appears necessary: __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ 14. Does your child have any additional medical needs that the school should be aware of, if so please give details below and provide additional information separately. _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ 15. For returning students only: If you are not sure about the medical information the school already has for your child/children please ask the office to show you the form you have previously signed. Name of Parents: _________________________________________________________________ Date: ________________________________ Signature: ________________________________ 16. Physician's Analysis (only for new students or change of circumstance): On the basis of this child's history, physical examination and other data, the following statement is applicable: (please check) ( ) This child is in excellent health, and no significant abnormalities are noted. ( ) This child is in good health, but the following abnormalities should be noted: _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ Date: ____________________ Signature of Physician: _______________________________ Name, Address and phone number of Physician _____________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________