Lentera Sastera Programme

12 – 14 Mac 2013

Health Form
You must inform the First Aider at the BEGINNING of the training should there be any change in the
information below.
Name: ___________________________________________
Contact No: _______________________________________
School: __________________________________________

1. Have you been in contact with any infectious illness during the last four weeks? *Yes/No
If yes, please state illness:
______________________________________________________________________________
2. Does your health require special care or supervision in any way?
If yes, please give details:

*Yes/No

______________________________________________________________________________
3. Please list dietary needs (on religious or medical grounds only).
______________________________________________________________________________
4. Are you allergic to any drug/medication?
If yes, please state the name of the drug/medication:

*Yes/No

______________________________________________________________________________
5. Blood Group:
______________________________________________________________________________

******************************************************************************
In case of emergency, please contact:
Name: ___________________________________________

Relationship: _____________

Home Address: ________________________________________________________________
Contact Number: ___________________________________________ (Home/HP/Office/Pager)
*Delete where not applicable

4 108 50.903088        ******************************************************************************    4084:70.  08...9706:70850.70478:507.8089.3.8433..

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