Pakuranga.cn

P A K U R A N G A C O L L E G E
STUDENT'S HEALTH RECORD
Could you please complete the following in BLOCK CAPITALS.

Student's Surname .

OVERSEAS EMERGENCY CONTACT

Does your son/daughter have, or has
Please delete Details/Medication required at present
he/she ever suffered from:
…………………………………………………………………………. (In the event of an asthma emergency, where your child does not have his/her medication with him/her, please sign your permission below allowing our emergency Ventolin inhaler to be used.) YES/NO Signature ……………………………………………………………………
If YES, when was the last seizure?
…………………………………………………….…………… Blood-borne viruses? (eg. Hepatitis, HIV) .…………………………………………………………………….……………. ……………………………………………………………………………….…… .……………………………………………………………………………. contact lens/hearing aid? Does he/she suffer from any other medical Does he/she take, on a regular basis, any Has your student had a Tetanus vaccination course? Has your student had a Tuberculosis YES/NO Signature ……………………………………………………………………
Additional Comments:
…………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………… ……………………………………………………………………………………………… SPECIAL MEDICATION SHOULD BE LEFT WITH OUR NURSE AT THE HEALTH CENTRE

The information requested overleaf is required in order to provide the school with appropriate medical knowledge relating to your child
and the means to make contact if necessary. It will not be used for any other purpose. If the school is unable to make contact with
those named above, in an emergency the school will seek appropriate medical assistance.
You are requested to sign this form giving permission, in the case of an emergency, for this information to be passed on to a doctor or
hospital, for the school to seek medical advice and also indicating your acceptance of the responsibility to reimburse the school for
reasonable costs incurred.
Parents' Names . .
(Please print)
Date ………………………………………………

Source: http://pakuranga.cn/upload/userfiles/files/Students-Health-Record-Form-International.pdf