Medical Information Form

Medical Information Form
The following information is requested so that St. George’s staff or their agents employed to support extra-curricular programmes (e.g. ski camp staff, clubs supervisors, etc, known henceforth as “agents”) can make sensible decisions about administering basic medical care/first aid where necessary. For serious incidents, St. George’s staff would of course act only on the advice of qualified medical personnel and every attempt would be made to contact you first.
Nous vous demandons les informations suivantes afin que le personnel de l’école St. Georges ou ses agents employés dans le cadre de programmes extra-scolaires (personnel des camps de ski, superviseurs des clubs, etc., ci-après dénommés « les agents ») puissent prendre des décisions éclairées concernant l’administration de soins médicaux de base et de premiers secours en cas de besoin. En cas d’incident grave, le personnel de St. Georges n’agira bien sûr que sur les conseils d’un professionnel médical qualifié et tout sera fait pour vous contacter en premier lieu.

However, should we or the medical staff be unable to contact you immediately, the information below will help us to make swift, informed decisions about the welfare of your child. Please fill out all boxes as completely as possible now. You are responsible for keeping the school office updated of any changes to the information below, including contact numbers. For your child’s health and welfare, it is important that this form is as up-to-date as possible.
Toutefois, si nous ou le personnel médical ne sommes pas en mesure de vous contacter immédiatement, les informations ci-dessous nous aideront à prendre des décisions rapides et éclairées concernant le bien-être de votre enfant. Merci de nous fournir le plus d’informations possible. Il vous incombe de prévenir l’administration de l’école de tout changement apporté aux informations ci-dessous, y compris les numéros de contact. Pour la santé et le bien-être de votre enfant, il est important de garder ce formulaire à jour.

Pupil Information
Pupil's Name*

First NameLast Name
Date of Birth*

DayMonthYear
Year Group*
Contact Person*

First NameLast Name
Relationship to child*
Home phone*

Area CodePhone Number
Mobile phone*
Email or other
Medical Insurance Details

Day pupils and Weekly Boarders only
Health Insurance Provider
Address of Provider
Policy number or plan
Family Doctor
Doctor's Name*

First NameLast Name
Address*
Contact number*

Area CodePhone Number
YesNo
Details
YesNo
Details
YesNo
Details
YesNo
List here any exceptions i.e. medication that you know your child is allergic to or is otherwise

Special Dietary Requirements
YesNo
Details
Nationality as stated on passport
Passport No
Full Name on Passport
VISA no(If applicable)

Oral (Dental) Screening
From August 2024, pupils will benefit from free oral (dental) screening.

The screening will be conducted by dentist Sophie Desmons and her clinical team. The exam will help detect possible cavities and determine if your child needs care from a dentist or orthodontist. After the screening, the dentist will give the pupil a document summarising what was observed.

Please note that this examination will not allow a complete examination of the teeth (a complete examination would take more time and require x-rays), which is why we encourage you to continue to consult your dentist for regular check-ups.

À partir d'août 2024, les élèves bénéficieront d'un dépistage bucco-dentaire gratuit.

Le dépistage sera effectué par la dentiste Sophie Desmons et son équipe clinique. L'examen permettra de détecter d'éventuelles caries et de déterminer si votre enfant a besoin de soins auprès d'un dentiste ou d'un orthodontiste. A l'issue de l'examen, le dentiste remettra à l'élève un document résumant ce qui a été observé.

Veuillez noter que cet examen ne permet pas un examen complet des dents (un examen complet prendrait plus de temps et nécessiterait des radiographies), c'est pourquoi nous vous encourageons à continuer à consulter votre dentiste pour des contrôles réguliers.
Yes, I consent / Oui, je consensNo, I do not consent / Non, je n'y consens pas

General Declaration
The following information is requested so that St. George’s staff or their agents employed to support extra-curricular programmes (e.g. ski camp staff, clubs supervisors, etc, known henceforth as “agents”) can make sensible decisions about administering basic medical care/first aid where necessary.

For serious incidents, St. George’s staff would of course act only on the advice of qualified medical personnel and every attempt would be made to contact you first.

However, should we or the medical staff be unable to contact you immediately, the information in this form will help us to make swift, informed decisions about the welfare of your child.

Please fill out all boxes as completely as possible now. You are responsible for keeping the school office updated of any changes to the information below, including contact numbers. For your child’s health and welfare, it is important that this form is as up-to-date as possible.

We share medical data just for purpose of health of your child with medical personnel. Your child’s medical data will be deleted one year after your child’s end of attendance at our school. For more information you can read our Privacy Notice on our web site: https://stgeorges.ch/terms.
The Parent listed as the Parent or Guardian above should complete the boxes on the right and sign below.
YesNo
Separate details to be attached

Upload a File

Cancelof
YesNo
YesNo
To the best of my knowledge, the information I have given above is correct. I will make every attempt to keep St George’s school office updated of any changes to this form throughout the school year.
Parent or Guardian*

First NameLast Name
Date*

DayMonthYear
Signature of Parent or Guardian (valid as paper and pen signature)*
Enter the message as it's shown*
Should be Empty:

Medical Information Form

Pupil Information

Medical Insurance Details

Family Doctor

Special Dietary Requirements

Oral (Dental) Screening

General Declaration