International Montessori Nursery

‫حضا نة المونتيسورى العالمية‬

Student Health Form
Please complete this health information form and scan and return it to the nurse by email to:
princip@eim.ae. The information provided will remain confidential by all staff. Please help us to keep
your child safe by providing any details that we need to be aware of. Failure to do so may jeopardize the
safety of your child.

Name of child: Gender:

Nationality: Date of Birth:

Mother’s mobile: Emergency Contact person:

Father’s mobile: Emergency Contact Number:

Has your child had any of the following?

Health Conditions Yes No

Infectious Disease Yes No Serious injuries
Recurrent Infections
Diphtheria
Allergies (food or medication)
Measles
Skin problems
Mumps
Heart problems
Poliomyelitis
Diabetes
German Measles
Epilepsy
(Rubella)
Asthma
Scarlet Fever
Surgical Operations
Tuberculosis
Blood disorders
Whooping Cough
Vision Problems
Meningitis
Wears glasses
Chicken Pox Hearing Problems
Other Other

Please explain any Yes responses in more detail including treatment, medication- past or present and any
past or present illnesses, physical or emotional concerns not mentioned on this form i.e. behavioural
problems, disrupted schooling etc. (If applicable please attach any reports).

PO Box 48371, Abu Dhabi, UAE - Tel: 02 558-0062, Fax: 02-558-0072 - E-mail: princip@eim.ae, Website: www.imn.ae
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‫حضا نة المونتيسورى العالمية‬

Consent for Treatment:

Yes / No
The school has permission to take my child to the Health Clinic and be evaluated by the
(please circle) School Nurse or First Aid Trained Staff in the event of illness or injury at school. She will
perform basic first aid and or any appropriate non-invasive procedures necessary following
her assessment.

Emergency Treatment:
The school nurse will make every attempt to contact you should an emergency arise.

Yes / No In the event parents cannot be contacted, I authorise and empower the International
Montessori Nurse or a School Administrator to taking appropriate action by contacting the
(please circle) emergency services or escorting my child to hospital.

School Screening:
Students will routinely checked by the nurse; to include height, weight and basic health checks, as per the
Department of Health guidelines.

Yes / No

(please circle)
I give consent for routine health checks to be carried out in accordance with the Department
of Health.

External medical advice:

Yes / No
I agree, if advised by the school Nurse and or school Principal, to take my child for further
(please circle)
examination by a registered practitioner and provide a certificate if considered necessary
in the general interests of health and safety in the school.

Parent/Guardian’s name: ………………………………………………………….

Signature: ……………………………………….. Date: …………………………

Please scan a copy of your child’s vaccination record and health insurance card with this Student
Health Record and send it to: princip@eim.ae

Consent to Administer Prescribed Medications:

PO Box 48371, Abu Dhabi, UAE - Tel: 02 558-0062, Fax: 02-558-0072 - E-mail: princip@eim.ae, Website: www.imn.ae
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 International Montessori Nursery
‫حضا نة المونتيسورى العالمية‬
I request and authorise that my child be given the appropriate non-prescribed medicine in the
following cases:

Administration of Epinephrine in acute allergic reaction (anaphylactic shock) Yes No

Administration of Salbutamol Inhaler to control asthmatic symptoms Yes No

Administration of Oral Glucose for hypoglycemia Yes No

Administration of Paracetamol to control mild to moderate pain and fever Yes No

Application of ointments for insect bites, minor wounds etc. Yes No

Signature of Parent: Date:

Please note that Epipens and inhalers must be provided by parents.

Should your child be prescribed a medication which is required during school hours, it will only be given
with completed appropriate documentation from the doctor. If you give your child any medication before
he/she comes to school, please inform the nurse.

Medication including paracetamol/calpol etc. cannot be given by the school nurse without prior permission
from a parent/guardian. It is the parent’s responsibility to ensure that any change of contact numbers are
provided to the school office without delay.

IMPORTANT INFORMATION

Please ensure that you have provided an emergency telephone number that will be available at all times.

This form is valid for the entire duration the student is enrolled at the International Montessori Nursery.

Please inform the health clinic immediately should your child’s health change during their enrollment at the
International Montessori Nursery.

Please note that we cannot be held responsible for any outstanding medical information or condition that has

not been supplied. We can only act on the information supplied. It is the parent’s responsibility to inform

International Montessori Nursery of their children’s medical condition or allergies.

PO Box 48371, Abu Dhabi, UAE - Tel: 02 558-0062, Fax: 02-558-0072 - E-mail: princip@eim.ae, Website: www.imn.ae
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Version 3 Last updated 24.04.18