Health Declaration Form

HEALTH DECLARATION FORM

To prevent the spread of Coronavirus into our community and to reduce the risk of exposure to our staff and students, we are requesting for all personnel and visitors to complete this health declaration form. Your participation is important to help us take precautionary measures to protect you and everyone in our premise. Thank you for your time.
Branch 分行 *

Joyous Kiddy Preschool - JB Eco Botanic Joyous Kiddy Preschool- Ipoh Seri Botani Joyous Kiddy Therapy Centre - Johor Bahru Joyous Kiddy Therapy Centre- Ipoh Joyous Kiddy Learning Centre - JB Taman Gaya Joyous Kiddy Learning Centre - KL Pudu Joyous Kiddy Learning Centre - KL Puchong
Full Name 姓名 *

First Name Last Name
Phone number 联系号码 *

Area Code Phone Number
NRIC NO 身份证号码 *
What is your Gender? 性别 *

Male 男性 Female 女性
Address 住家地址 *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Mode of Transport 交通工具类型 *

Own Driving 自驾 Grab/Taxi 德士 Bus 巴士
Last place before departing to Joyous Kiddy 抵达Joyous Kiddy 前的位置 *

From home 家里
Have you been or stayed in the same accommodation with anyone known to be infected by COVID-19 in the past 14 days? 请问您在过去14天内是否有与COVID-19确证患者一同居住呢？ *

Yes 有 No 无
Have you been in close contact with person suspected to have COVID-19 您是否有与Covid-19确证患者亲密接触呢？ *

Yes 有 No 无
Are you suffering from any flu, cold, throat, cough, running nose or other flu like symptoms in the past 14 days 您是否在过去的14天内有出现伤风，感冒，喉咙痛，咳嗽或其它类似伤风感冒的症状呢？ *

Yes 有 No 无
Please indicate when and what symptoms 如有症状，请您注明年月日以及您的症状；
Next destination from our Joyous Kiddy 请注明您离开Joyous Kiddy之后的下一个目的地 *

Back home 回家
FOR OFFICE USE
Check in Temperature (for walk in client)
Degree Celsius
Check out Temperature (for walk in client)
Degree Celcius
Should be Empty:

HEALTH DECLARATION FORM

FOR OFFICE USE