International School of Kigali-Rwanda
Engaging Individuals | Encouraging Success | Enriching Global Citizens
Health Office: Student Health Information
2015/2016
We ask families to fill out health forms EVERY year to assure that information is current.
Please fill out form and return to the ISKR Office.
To be completed by parent or guardian PLEASE PRINT LEGIBLY
Name:
Student’s Full Name __________________________________________________________________________
Last
Male _____
Female ______
First
Middle
Grade ______
Date of Birth______________
(DD/MM/YYYY)
Parent phone
1.
Parent Names:
2.
Parent email
Physician in Kigali:
Physician Phone number:
Emergency Contact Information
Please Name an Adult in Kigali who can be contacted in case of Emergency if you/guardian are not available
Name
Phone number
1
2.
Email address
Relationship
Medical Information:
Does your child have any medical condition? (ie: seizure, asthma, diabetes, etc) If yes, please
explain:
*Is your child on long-term medication? If yes, please list medications, dosage and timing. (Any
medications that will be administered at school will require completing a Medication administration form.)
Is there any medical reason your child is not allowed to participate in sports/PE class? If yes,
please explain:
1
Does your child have any allergies? If yes, please explain in detail: allergy, severity and course
of treatment (including dosages and/or epi-pen). Please supply Health Office with allergy
medication in case of allergic reaction while at school.
Has your child been hospitalized in the last year? If yes, please explain.
Has your child received all childhood vaccinations? (Please attach immunization records. See
attached Rwandan Immunization schedule / minimum requirements for ISK-R)
Does your child currently have or have a history of Yes
No
any of the following problems?
Learning Disabilities
ADD/ADHD
Speech/Language problems
**Asthma
Head injury
Fractured bones
Muscular/skeletal problems
Sickle Cell Anemia
Diabetes
Ear problems
Seizures or convulsions
Meningitis
Mental Health problems (ie depression, anxiety,
panic attacks)
Nutritional Restrictions (for religious or other
reasons)
Skin problems
Urinary disorders
Scoliosis
Heart or lung disorder
Other:
**If your child has asthma, we ask you to purchase an inhaler to be kept at the health office
for emergencies. (We have needed this with even very stable asthma in the past.)
If you answer yes to any of the questions, please describe below if not already described
earlier in form (include age of onset and age resolved if relevant, treatment etc).
2 – ISK-R Health Form
Please add any additional information that you feel is relevant for the health office to know
and/or attach any reports.
PLEASE KEEP THE HEALTH OFFICE INFORMED OF ANY CHANGES IN YOUR CHILD’S HEALTH.
1. I give permission for discreet use of personal medical information to meet my child’s
health and educational needs at school. (i.e.: discussing with classroom teacher)
Yes_____ No_____
2. I give permission for emergency measures to be initiated in case of accident or sudden
illness with the understanding that I will be notified at the above phone numbers.
Yes_____ No_____
3. In case of emergencies that cannot be handled at school the hospital of choice for ISK
is King Faisal Hospital. If it is an emergency, I give permission for my child to be
transferred there with an adult with the understanding that I will be notified via phone
Yes_____ No_____
4. I give the health office permission to treat my child with over-the-counter
medications(check all that apply) at school for minor complaints. You will be notified
of all treatments by note sent home.
__ Paracetamol (acetaminophen)
__ Ibuprofen __ Throat lozenge
__ tummy antacid (calcium carbonate) __ antihistamine (for allergic reactions)
__ hydrocortisone cream (for itches/bites)
Parent Signature _____________________________________________________________
Date (DD/MM/YYYY)_____________________________
Please contact the Health Office directly with any questions or concerns at the main office #
0786725369.
3 – ISK-R Health Form
Rwanda National Vaccine Preventable Disease Division immunization schedule
Vaccine
Total doses
Age and interval
BCG (not required for ISK students)
1
Birth
OPV/IPV (Polio)
4
Birth, 6, 10, 14 weeks
DTP or DTP-HepB-Hib
3
6, 10, 14 weeks
Pneumococcal Conjugate Vaccine
3
6, 10, 14 weeks
Rotavirus vaccine1 (not required for
ISK students)
3
6, 10, 14 weeks
Measles-rubella (MR vaccine)
1
9 months
Measles vaccine2
1
15 months
HPV3 (not required for ISK students)
2
girls 12 yrs old
1
Above the age of 9 months
2
at school entry age(4-7 years)
and
(diphtheria, tetanus, Hepatitis B and
Haemophilus influenzae)
Other vaccines to consider:
Yellow Fever vaccine required for
entry into Rwanda
CDC recommends Typhoid vaccine
WHO recommends Tetanus booster
dose for children
in adolescence (12-15years)
Different regions in the World use different schedules. These are the basic vaccination
requirements for Rwandan children. We recommend the same for students entering ISKR.
1
Rotavirus vaccine is given in 3 doses, the first dose no later than 15 weeks of age and the last dose by 32 weeks of age
Second dose of measles vaccine will be introduced in 2013: MR vaccine at 9 month and measles vaccine alone at 12 months of
age
3
Human papilloma virus vaccine (HPV) will use a school based vaccination campaign approach
2
4 – ISK-R Health Form