STUDENT HEALTH DECLARATION FORM

STUDENT HEALTH DECLARATION FORM

To support student wellbeing at King’s, all parents have to complete this Health Declaration Form for each child. This form is designed to gather information on your child’s current medical condition, allergies, asthma and symptoms that may affect their wellbeing during school hours. This information is important for the school nurses to have, in order to help support your child’s wellbeing sufficiently in case of any emergencies or other needs of medical attention.
Student Information
Name*

First NameLast Name
Nickname*
Year*
Date of Birth*

MonthDayYear
Date
Gender*

MaleFemale

Dietary Requirements
Emergency Contact Information
Name*

First NameLast Name
Relationship*
Contact Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Which hospital is your child registered with?*
Does your child have a Primary Physician (if so please give us their name)
Administering of medication at school
I consent to the school nurse administering (as per instructions on the pharmacy label and/or any additional written instructions) the following medications to my child during school hours or school-related activities

Please tick the medication that you allow for the nurse to administer to your child
Pain Relief:
Antihistamine:
Cold and Cough:
Anti-diarhea and Antacids:
Antiemetic / Antihistamine
Declaration and Understanding

By signing below, I declare that the information I have provided on this form is true to the best of my knowledge. I understand that the form is solely for the school’s nurse’s informational purposes in order to be able to support my child in the event where administering medical/emergency treatment is needed.

I hereby consent to the school nurse administering medical treatment as needed, and to refer to hospital care for further treatment should this be deemed necessary for my child.

I understand that my responses on this form do not impose any obligations on King’s College International School Bangkok to manage or address my child’s health condition.

I acknowledge it is my responsibility to promptly inform the school nurse of any changes in my child’s health status that could impact my child’s health and wellbeing.
Parent Signature*

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STUDENT HEALTH DECLARATION FORM

Student Information

Health Declaration

Emergency Contact Information

Administering of medication at school

Declaration and Understanding