Parents & Children’s Health Declaration Form

Parents & Children’s Health Declaration

Name of children：

Mother’s Name： I.C. Number：

H/P Number：
Father’s Name： I.C. Number：
H/P Number：
Email Address：
Home Address：

Mother’s/Father’s Hometown Address：

Tel. Number:

Siblings’ Information

Health status：Past 14 days

*Mark (/) the answer for “Yes”
Name Age
Breathing
Fever Cough Flu Sore throat Others
Problems
1

2
3

5
6
7

During the Movement Control Order period, did your children and his/her siblings live with parents? If
not, please state the address and the relationship between the child(ren) and the guardian.
Guardian’s Address:
Guardian-child relationship:

Did any family members/others live with you(parents) and your child(ren) during the Movement Control
Order Period?

Yes or No
Travel history during the Movement Control Order Period. Has your child ever:
Go abroad. If Yes, please list the country:
Went to hospital or visited any patient
Attended a public meeting
Participated in any religious gatherings
Participated in any big event gathering
*Mark (/) the answer for “Yes”

Have you (parents) been in close contact with someone with a confirmed novel coronavirus (Covid-19)
patient or who is under the “Home Quarantine Order” or someone suspected of COVID-19 in the past 14
days?

Yes or No

Have your child(ren) been in close contact with someone with a confirmed novel coronavirus (Covid-19)
patient or who is under the “Home Quarantine Order” or someone suspected of COVID-19 in the past 14
days?

Yes or No

I, ..........................................................., IC Number, .............................................. as a

mother/father/guardian will not send my child(ren) to the kindergarten if my child(ren) is found to be sick
or ill. I understand that the kindergarten has the right not to accept students who do not meet health
standards. Children should be referred to the hospital for medical attention.

I declare all the above to be true and correct. By submitting this declaration form, I agree to the collection,
use, and disclosure of my personal information above for the purposes of a precautionary measure against
COVID-19 .

I.C. Number:

Signature: Date: