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MEDICAL INFORMATION FORM
CHILD'S DETAILS
Student Name
Date of Birth
Class
Gurdian Name (1)
Gurdian Name (2)
Mobile No (1)
Mobile No (2)

In case of an emergency and we are unable to reach the student's guardian, we can contact:

Name
Phone no.
Mobile no.
Name
Phone no.
Mobile no.
Family doctor's name
Mobile no.
Referral Hospital
File no.
Previous childhood diseases:
Other
Has your child been inoculated against
Polio / Tetanus / Diphteria
Measles, Mumps, Rubella (MMR)
Meningitis
B.C.G (TB)
Hib (Hemophilus influenza)
Hep B (Hepatitis B)

Based on the requirements of the Saudi Ministry of Health, the Ministry of Education instructs that all children attending school must be vaccinated against communicable diseases. However, if for any special reason you have not vaccinated your child(ren), kindly present the School with a letter from an accredited hospital in KSA, stating the reason for such a decision.

Furthermore, should your child show in school symptoms of a communicable disease, he/she will need to remain at home until a medical professional declares he/she is safe to return to school.

Does your son/daughter suffer from any of the following conditions? (If yes, please explain in detail)
Heart disease
Diabetes
High/Low Pressure
Hearing problems/ Speech problems
Asthma
Muscle or bone problems
Severe headache
Anemia or blood diseases
Eye problems/ Glasses/contact lenses
Fainting/dizziness
Convulsions/Epilepsy
Nose bleeding
If you answered "Yes" to any of the above medical conditions, please explain in detail.
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Allergies
Type of allergy:
To be done when allergies occur:
A medical condition that interferes with sports activity:
MEDICAL TREATMENT AUTHORISATION AND DECLARATION

Non-emergency Medical Treatment

The following medications are held by the school


Name of medicineTreating
Fevadol Pain reliever and antipyretic
Fucidin Antibiotic cream for wounds or infected skin
Mebo creamCream for the treatment of wounds and/or burns
Flamazine creamTo treat burns
IboprufenPain reliever and antipyretic
Antihstamines To treat allergy
StrepsilsTo treat sore throat
AUTHORISATION

It may be that you would not wish your child to receive these or other medication at all for non-emergencies.

However if you would like your child to be able to be given any of these mild treatments, the school requires your written authorization below.

Please note that the Medical staff will not administer any medication to your child without your authorization. You should therefore accept that your child could remain in discomfort if we have no authorization to administer one of the mild medications.

I am the guardian of the student:

We appreciate that sometimes the student has to take home-sent medication during school hours, so if you wish the nurse to give it to your son/daughter, kindly


1. Drop the medication and doctor prescription in the clinic attached with the following information

  • Medication name
  • Dosage
  • Time of administration
  • The reason for giving this medicine
  • Duration of treatment

2. Sign the “Home Prescribed Medication Form” with the school nurse. Valid for 1 academic year or as long as the medication is needed.


Emergency Medical Treatment
I authorize Nün Academy to transfer my child to a medical center in case of emergency
Parent/Guardian name:
Date
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