GEMS American Academy                                   Health Declaration Form
Please complete one form per child
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Your email address *
Child's Full Name *
What grade is your child in?
Does your child suffer from any chronic illnesses?
Please answer the following questions
Diabetes Mellitus *
Hypertension *
Chronic respiratory diseases such as Asthma *
Cardiac disease *
Kidney disease *
Liver disease *
Autoimmune disease *
Haematological disorders *
Is your child on any immunosuppressant medication? *
Other (if your son/daughter suffers from any other chronic diseases, please specify) *
Has anyone in your household been diagnosed with COVID-19? *
If yes, when?
Has your child, in the past 14 days, come in close contact with someone diagnosed with COVID-19?   *
Has your child had any fever or respiratory symptoms “coughing, sneezing, loss of the sense of smell or taste, trouble breathing, headache, sore throat, runny or stuffy nose” in the past 3 days? *
Has anyone in your household traveled to any other country in the past 21 days? *
If yes, please specify
Please provide any additional health-related information you wish to share with the school’s nurse:
Please read the following declaration and add your name below as a digital signature of your confirmation that your responses are correct and complete.
I, hereby confirm that the information that I have provided in this declaration form is correct and complete.

I undertake not to send my child to school if he develops any COVID-19 symptoms.

In case any of the above information is found to be false, untrue, misleading, or misrepresenting, I am aware that I may be held liable.

If any of the above information about my child or household changes, I will immediately notify the school nurse.
Name of Parent or Legal Guardian
Your Emirates ID Number
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