We ask families to fill out health forms EVERY year to assure that information is current. Please fill out form and return to the ISKR Office.
To be completed by parent or guardian PLEASE PRINT LEGIBLYName:
Student’s Full Name ______
Last First Middle
Male _____
Female ______Grade ______Date of Birth______
(DD/MM/YYYY)
Parent Names: / Parent phone
1.
2.
Physician in Kigali:
Physician Phone number: / Parent email
Emergency Contact Information
Please Name an Adult in Kigali who can be contacted in case of Emergency if you/guardian are not availableName / Phone number
1
2.
Relationship / Email address
Medical Information:
Does your child have any medical condition? (ie: seizure, asthma, diabetes, etc) If yes, please explain:*Is your child on long-term medication? If yes, please list medications, dosage and timing. (Any medications that will be administered at school will requirecompleting a Medication administration form.)
Is there any medical reason your child is not allowed to participate in sports/PE class? If yes, please explain:
Does your child have any allergies? If yes, please explain in detail: allergy, severity and course of treatment (including dosages and/or epi-pen). Please supply Health Office with allergy medication in case of allergic reaction while at school.
Has your child been hospitalized in the last year? If yes, please explain.
Has your child received all childhood vaccinations? (Please attach immunization records. See attached Rwandan Immunization schedule / minimum requirements for ISK-R)
Does your child currently have or have a history of any of the following problems? / Yes / No
Learning Disabilities
ADD/ADHD
Speech/Language problems
**Asthma
Head injury
Fractured bones
Muscular/skeletal problems
Sickle Cell Anemia
Diabetes
Ear problems
Seizures or convulsions
Meningitis
Mental Health problems (ie depression, anxiety, panic attacks)
Nutritional Restrictions (for religious or other reasons)
Skin problems
Urinary disorders
Scoliosis
Heart or lung disorder
Other:
**If your child has asthma, we ask you to purchase an inhaler to be kept at the health officefor emergencies. (We have needed this with even very stable asthma in the past.)
If you answer yes to any of the questions, please describe below if not already described earlier in form (include age of onset and age resolved if relevant, treatment etc).
Please add any additional information that you feel is relevant for the health office to know and/or attach any reports.
PLEASE KEEP THE HEALTH OFFICE INFORMED OF ANY CHANGES IN YOUR CHILD’S HEALTH.
- I give permission for discreet use of personal medical information to meet my child’s health and educational needs at school. (i.e.: discussing with classroom teacher)
- I give permission for emergency measures to be initiated in case of accident or sudden illness with the understanding that I will be notified at the above phone numbers.
- In case of emergencies that cannot be handled at school the hospital of choice for ISK is KingFaisalHospital. If it is an emergency, I give permission for my child to be transferred there with an adult with the understanding that I will be notified via phone
- I give the health office permission to treat my child with over-the-counter medications(check all that apply) at school for minor complaints. You will be notified of all treatments by note sent home.
__ tummy antacid (calcium carbonate) __ antihistamine (for allergic reactions)
__ hydrocortisone cream (for itches/bites)
Parent Signature ______
Date (DD/MM/YYYY)______
Please contact the Health Office directly with any questions or concerns at the main office # 0786725369.
Rwanda National Vaccine Preventable Disease Division immunization schedule
Vaccine / Total doses / Age and intervalBCG (not required for ISK students) / 1 / Birth
OPV/IPV (Polio) / 4 / Birth, 6, 10, 14 weeks
DTP or DTP-HepB-Hib
(diphtheria, tetanus, Hepatitis B and Haemophilus influenzae) / 3 / 6, 10, 14 weeks
Pneumococcal Conjugate Vaccine / 3 / 6, 10, 14 weeks
Rotavirus vaccine[1] (not required for ISK students) / 3 / 6, 10, 14 weeks
Measles-rubella (MR vaccine) / 1 / 9 months
Measles vaccine[2] / 1 / 15 months
HPV[3] (not required for ISK students) / 2 / girls 12 yrs old
Other vaccines to consider:
Yellow Fever vaccine required for entry into Rwanda / 1 / Above the age of 9 monthsCDC recommends Typhoid vaccine
WHO recommends Tetanus booster dose for children / 2 / at school entry age(4-7 years) and
in adolescence (12-15years)
Different regions in the World use different schedules. These are the basic vaccination requirements for Rwandan children. We recommend the same for students entering ISKR.
1 – ISK-R Health Form
[1]Rotavirus vaccine is given in 3 doses, the first dose no later than 15 weeks of age and the last dose by 32 weeks of age
[2] Second dose of measles vaccine will be introduced in 2013: MR vaccine at 9 month and measles vaccine alone at 12 months of age
[3]Human papilloma virus vaccine (HPV) will usea school based vaccination campaign approach