The Purple Elephant welcome form

STUDENT HEALTH RECORD

The information provided here will remain confidential and is for school use only.
CHILD AND FAMILY DATA
Child's Name*

First NameMiddle NameLast Name
Nickname
Birth Date

MonthDayYear
Campus*
New or Returning Student*
Year Level*
Year Level*
Teacher's name
Father's Name

First NameLast Name
Phone Number

Country CodePhone Number
Email
Mother's Name

First NameLast Name
Phone Number

Country CodePhone Number
Email
Languages Spoken (Child)
Siblings (Brothers/Sisters)
Home Address
EMERGENCY CONTACT

(in the event of not being able to contact either parent)
Name*

First Name & Last NameRelationship
Phone Number*

Country CodePhone Number
Child's Doctor
Hospital

PERMISSION TO USE PHOTOS/IMAGE/ARTWORK

The ELC International School records various school activities as part of developing promotional materials and our website. These may include the use of your child’s photograph and/or image, as well as artwork or other materials created by your child and/or the recording and/or transcription of dialogue spoken by your child. Your child’s first name only might be used when including dialogue from project work.

We would like to request your permission to use your child's image and work as mentioned above. Should you have any questions, please do not hesitate to contact us.
Signature*

Clear
Date

DayMonthYear
Should be Empty:

	YES	NO	Specific Details
Allergies to Food, Medication, Environmental Factors, or Bee/Wasp Stings
Asthma
Chronic Illness
Epilepsy
Febrile Seizure / Convulsion
Developmental Problems, Challenges or Disabilities
G6PD Deficiency
Hearing Problems
Surgery
Thalassemia
Vision Problems
Further details concerning any of the above

	YES	NO	Specific Details
My child takes regular medication
My child requires emergency medication to be kept at school