To prevent the spread of Coronavirus Disease (COVID 19) and reduce the risk of exposure to our center,

teachers and children, we are conducting a simple screening questionare. Your cooperation is
important to help us to take precautionary measures to protect everyone in this premise.Thank you.

HEALTH DECLARATION FORM

Childen's Name : Mykid No :

Father's Name : NRIC :
Contact No :
Mother's Name : NRIC :
Contact No :
Address :

Health Declaration of Parents, Children, Family Members

No Name Age Health Condition in past 2 weeks

Tick (/) for 'YES'
Fever Cough Flu Sore Breathing
throat difficulties
1
2
3
4
5

Self Declaration

14 days risk (please tick) YES NO

Have you & your children returned from overseas in the past 14 days?
if Yes, please state the country visited
Did you & your children attend any gatherings identified as clusters
by MOH in the past 14 days
Are you a close contact of a confirmed COVID-19 person
a) Any of your family household members being confirmed
positive for COVID 19
b) Have you & your children been together in an air conditioned confined
space for more than
Declaration
I ……………………………………………………………………… NRIC ………………………………………………… the
father/mother/guardion of …………………………………………………………………… hereby acknowledge that I will not
sent my children to kindergarten if I find my children is not well. I understand that kindergarten has the right
not accepting my children if they are not fit to attend the class.

Signature ………………………………………………….. Date ………………………………