HEALTH DECLARATION FORM

All children coming to Brainy Bunch are required to finish up all the information in this Form

PART A (General)

Child’s Name: NUR DINNY NAURAH Parent’s Name: M NASRUN BIN MASTOR

Gender: Girl Age: 6 years old MyKid No: 151217-10-0378

Campus Name: TTDI GROVE KAJANG

H/P No: (M) 019-3532513 H/P No: (D) 017-6157352

Home Address: NO. 17, JLN TPS 4/3, TAMAN PELANGI SEMENYIH, 43500, SEMENYIH, SELANGOR

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PART B (COVID-19)

1. Have you been to any area or countries of COVID-19 as indicated by WHO over the past 14 days? (Yes/No)

2. Have you had any of the following symptoms over the past 14 days? Please tick, (Y/N).

Fever ( ) Cough ( ) Difficulty in breathing ( ) Sore throat ( ) Others:

3. Have you been in close contact with a person suspected to have COVID-19? (Yes/No)

If the answer is YES to all questions above, please do not send your child to the campus and please report yourself and family members
to the nearest Health Screening centres in your area.

Definition close contact:

1. Health care associated exposure, including providing direct care for COVID-19 patients, working with health care
workers infected with COVID-19, visiting patients or staying in the same close environment of a COVID-19
patient.

2. Working together in close proximity or sharing the same classroom environment with a with COVID19
patient

3. Traveling together with COVID-19 patient in any kind of conveyance

4. Living in the same household as a COVID-19 patient.

Signature: Date: