Affiliated to the Central Board of Secondary Education, New Delhi, Affiliation Number: 1931179 (PreKG to Grade 12)

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Annual Health Information Form

Please complete all the sections thoroughly, to enable us to update records.
(Parents / Students must send this completed form directly to the school office

Male Female

*If none of the above is available in an emergency, Please contact:

Address 1:

Address 2:

Known Allergies/Medical Conditions:

Asthma: Yes No
Mild: Attach are rare, limited mostly to tightness and wheezing.
Moderate: Occasional attacks which can be self managed using prescribed medication.
Severe: Attacks are regular, severe and have required hospital treatment.
Yes No
Please give additional information
Yes No
Yes No
Vegetarian; Non-Vegetarian;

I have completed this medical form accurately, truthfully, and to the best of my knowledge as of today’s date. I understand that it is my responsibility to inform the school of any new medical condition or change in this information.

I hereby give consent and full authority for the staff or agents of the school to arrange for and consent to any medical treatment or hospitalsation for my child / guardian while s/he is in the care of the school. I further authorise these staff members to enter into and execute, on my behalf, such documents or consents as may be required by Medical Practitioners, Health Care Professionals or Hospitals for such purposes.

You will be required to fill in a short form giving updated medical information since filling in this form during the year.

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