Imn.ae

International Montessori Nursery
In order to give your child the best possible school health and emergency care, please complete this form carefully. Emergency Contact other than yourselves. Student Health History
Does your child have any of the following? If yes please supply details such as specific diagnosis and current treatment. For allergies, specify allergies and note severity of allergies? P.O. Box 48371, Abu Dhabi, United Arab Emirates Tel.: (02) 558 0062 Fax.: (02) 558 0072 www.imn.ae E-mail :princip@eim.ae International Montessori Nursery
Please inform us of any circumstances which may affect your child’s schooling e.g. Physical Disability, Learning Disability, Behavourial Problems, Dyslexia, Disrupted Schooling, if applicable, (Attach any reports) Please describe any past or present serious illness, physical or emotions problems. Is your child on regular medication? If so, please list: P.O. Box 48371, Abu Dhabi, United Arab Emirates Tel.: (02) 558 0062 Fax.: (02) 558 0072 www.imn.ae E-mail :princip@eim.ae International Montessori Nursery
CONSENT TO ADMINSITER NON-PRESCRIBED MEDICINES
I request and authorize that my child ______________________________ be given the appropriate non-prescribed medicine in the following cases: 1. Administration of Calpol/Tynelol to control moderate pain and 2. Administration of Epinephrine in acute allergic reactions (Anaphylactic shock). (If your child has an Epi-pen this must be provided by the parents). 3. If you child is an asthmatic please provide his/her Salbutamol Inhaler. We require your permission to administer said inhaler to control Mild Asthma Symptom. 4. Application of ointments for insect bites, minor wounds and so P.O. Box 48371, Abu Dhabi, United Arab Emirates Tel.: (02) 558 0062 Fax.: (02) 558 0072 www.imn.ae E-mail :princip@eim.ae International Montessori Nursery
Please note that IMN will not give any medications unless this form is completed and signed. Name of Parent:_________________________________________________ Signature:______________________________________________________ CONSENT TO ADMINISTER PRESCRIBED MEDICINES
I request and authorize that my child _______________________________ be given the appropriate prescribed medicine in the following cases: Name of Medicine _______________________________________________ Time of Dose______________________ Dose_________________________ P.O. Box 48371, Abu Dhabi, United Arab Emirates Tel.: (02) 558 0062 Fax.: (02) 558 0072 www.imn.ae E-mail :princip@eim.ae International Montessori Nursery
Start Date _______________________ Finish Date____________________ This medication has been prescribed for my child by: Name of Physician______________________________________________ Phone number of Physician _______________________________________ I have confirmed that it is necessary to give this medication
during the school day. Please provide a photocopy of the
original prescription.
The medication must be in the original container indicating the contents, dosage and child’s full name. If there are any additional medial concerns, after the completion of this form, please notify the school nurse. Name & Signature of Parent ______________________________________ Date__________________________________________ IMMUNIZATION REQUIREMENTS AND CHECKLISTS
Required immunization (Must provide a copy of immunization record) DPT (Diphtheria, Pertusis, Tetanus) @ 2,4,6,& 18 months and at 4-6
years
Dates of immunizations:
Hepatitis B (HBV) 3 doses injectable at day 1, day 30, 6-12 months
Dates of immunizations:
HIB (Haemophilius Influenza) @ 2,4,5,&12-15 months
Dates of immunizations:
P.O. Box 48371, Abu Dhabi, United Arab Emirates Tel.: (02) 558 0062 Fax.: (02) 558 0072 www.imn.ae E-mail :princip@eim.ae International Montessori Nursery

MMR (Measles, Mumps, Rubella) @ 9 & 15 months and at 4-6 years
Dates of immunizations:
POLIO (oral OPV or injectable IPV) @ 2,4,6, & 18 months and at 4-6
years
Dates of immunizations:
TD (Tetanus, Diptheria) every 10 years after DPT
Dates of immunizations:
Any family unable to document these immunizations must consult with IMN’s school nurse. Recommended for all children and adults
BCG (Bacillus Calmette-Guerin)
Dates of immunizations:
Hepatitis A (Harvis) usually 2 doses injectable at day 1, 6-12 months
Dates of immunizations:
Meningitis usually injectable, given to 2+ years of age with a Booster
every 3 years.
Dates of immunizations:
Typhiodinjectable, 2 doses at 6 months – 5 years of age with a
Booster every 4 years (Oral dose given to 5+ years of age with
Booster every 4 years)
Dates of immunizations:
Varicella (Chicken Pox) for those who have not had a documented
case of chicken pox, 1 dose for children 1-12 years, 2 doses for over
12 years
Dates of immunizations:
OTHER OPTIONAL VACCINATIONS AND PREVENTIVE
MEASURES:
INFLUENZA Dates of immunizations: JAPANESE ENCEPHALITIS (B) 3 doses at day 0,7, & 30 P.O. Box 48371, Abu Dhabi, United Arab Emirates Tel.: (02) 558 0062 Fax.: (02) 558 0072 www.imn.ae E-mail :princip@eim.ae International Montessori Nursery
Dates of immunizations: MALARIAL PROPHYLAXIS Dates of immunizations: PNEUMOCOCCAL Dates of immunizations: RABIES (Pre-exposure) 3 doses at day 0, 7 & 28 Dates of immunizations: P.O. Box 48371, Abu Dhabi, United Arab Emirates Tel.: (02) 558 0062 Fax.: (02) 558 0072 www.imn.ae E-mail :princip@eim.ae

Source: http://www.imn.ae/download/Student%20Health%20Form.pdf