T: +971 (0)4 344 6931F: +971 (0)4 344 6754E: info@jbschool.ae

Jumeira 1, on 53B Street, off Al Wasl RoadPO Box 211829, Dubai, United Arab Emirates

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Medical and Immunisation Recordand

Consent Declaration

Confidential

Please insertstudent’s photo

here.

Child’s Name: _________________________________________

Please complete this form and return it to JBS prior to your child starting school.

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Compulsory on Acceptance

The information provided will be treated as confidential by all JBS staff. If you have any queries, please feel free to contact our Nurse, who will be happy to answer any questions.

Name of Child ____________________________________________________ Class ________________________________

Nationality _________________________________ Date of Birth _______________________ Gender M F

Father’s Name _____________________________________ Mother’s Name ______________________________________

Father’s Mobile ____________________________________ Mother’s Mobile ______________________________________

Physical Address ________________________________________________________________________________________

___________________________________________________ Home Telephone ____________________________________

Alternative Emergency Number(s)__________________________________________________________________________

Contact Person(s) ________________________________________________________________________________________

Please complete the following and tick ‘Yes’ or ‘No’ where applicable:

Illnesses Yes No Conditions Yes No

Please provide details for any of the above answered with ‘Yes’, inclduing treatment and regular medications (continue on a separate sheet if required):

Family History

Diabetes Hypertension Stroke Tuberculosis Other ________________________________________

History of: Blood Transfusion No Yes, Frequency ________________________________________________

Hospitalisation No Yes, Frequency ________________________________________________

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Compulsory on Acceptance

Please ensure all consents are signed and dated.

Parental Consent

As the parent/guardian of ________________________________________________ (please print the child’s name) I give consent to the following:

1. Consent for the administration of an over-the-counter medication

In the event that your child develops a fever or has pain it may be necessary to administer an over-the-counter medication. If your child is unable to take certain medications, please contact the school nurse to advise her so alternatives can be provided.

I consent to my child being given an over-the-counter medication such as Paracetamol or Neurofen should it be considered necessary by the School Nurse.

Parent’s Name (please print) _____________________________________________________________________________

Signature _______________________________________________________ Date ______________________________

2. Consent for emergency treatment

In the event that your child requires emergency treamtment you will be contacted and asked to collect your child from the school. If the school is unable to contact you, your child will be taken to a doctor/hospital for diagnosis and treatment. Efforts to contact you will continue.

I consent to my child being taken to a doctor/hospital in the event of a medical emergency.

Parent’s Name (please print) _____________________________________________________________________________

Signature _______________________________________________________ Date ______________________________

3. Consent for medical examination

According to school health guidelines children require a school physical at certain phase stages in their life (KG1, G1, G5, G9 and school leavers) and any child new to the Dubai School System.

This service is currently offered to you by JBS, however, if you wish to have your child examined by your own family GP you may do so at your convenience. The school will require a copy of the doctor’s report for your child’s health records. JBS has its own school doctor.

We would also like to reassure parents that the safety and wellbeing of the children are of prime importance to us and they are supervised at all times during the examination by the School Nurse.

As parents you will be notified prior to any examination taking place and will be given the opportunity to attend.

I consent to my child having a school physical.

Parent’s Name (please print) _____________________________________________________________________________

Signature _______________________________________________________ Date ______________________________

Please note that all consents are valid for the period of time your child is attending JBS.

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Compulsory On Admission

Immunisation History

The Department of School Health requires that the school maintains current information on each child’s immunisation history. It is therefore important that Jumeira Baccalaureate School has a copy of your child’s immunisation records.

JBS does not have an immunisation programme. Please make an appointment with your family GP for any required immunisations.

(Please tick the appropriate box)

I have attached a copy of my child’s immunisation records

I will bring a copy to the nurse’s clinic as soon as possible

Previous Dubai School

Please complete below if your child previously attended another school in Dubai.

Name of previous school ________________________________________________________________________________

We have the school health booklet in our possession and will bring it to the nurse’s clinic

As far as we aware the previous school still has the health booklet