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Emergency Medical Form

The following information will help QAIS personnel in providing adequate attention to your child's needs in the event of a medical emergency.

Health Information 健康信息
Allergies and Food Restrictions 过敏和饮食禁忌

Medication 药物治疗
Treatment 治疗
Participation in Physical Activities 参加体育活动
Student Health History 学生健康历史

Does your child have any of the following? If yes, please tick box and supply details such as specific diagnosis and current treatment. 您的孩子是否有以下疾病?如果有,请选择相应选项,并说明具体诊断和当前治疗等详细情况。

If your child has been diagnosed with any visual difficulty, or prescribed corrective lenses, please provide details of the diagnosis and prescription.
如果您的孩子被诊断有视觉困难或配戴矫正眼镜,请提供详细的诊断和处方信息。

Other Information 其他信息

Please indicate the name and phone number of the family’s preferred physician, if applicable. 如果有固定偏好的医生,请写出该医生的姓名和手机号码。

Please indicate whether the applicant has health insurance from an outside provider. 请标明学生是否有除学校之外另一方所购买的健康保险

Accident Treatment Permission 事故医治许可

I understand that all efforts will be made to contact parents first, emergency contacts second and if neither are available, I hereby give permission for emergency measures to be initiated in the case of accident or sudden illness. 我知道当有意外事故发生时,学校会首先竭尽全力地与家长取得联系,其次与紧急联系人获得联系,如果以上二者都无法获得联系,我特此准许学校给予紧急医治。

Failure to declare accurate and full medical information may result in annulment of the school’s acceptance offer or require withdrawal from the School. 如果未能提供精确、完整的健康医疗信息将会导致学校接收许可的取消或退学

Date: Mar 26, 2017