MEDICAL ALERT NOTIFICATION

Dear Parent,

Regular attendance at school is essential for effective learning. However, simply being present does
not guarantee productive learning experiences. To maximize learning, a child needs to be in good
health. Moreover, a sick child attending school risks spreading illness to others. It has been observed
that some students report to school on exam days and request early dispersal. Please note that the
school has a policy in place to conduct re-examinations for students who are medically unfit.
It is recommended that a child remains at home, if any of the following conditions are present.
i) Temperature of 1000 or higher.
ii) Vomiting and/or Diarrhea with a loss of Appetite and/or Fever.
iii) Pain that requires narcotic medication for relief.
iv) Conjunctivitis – Redness of Eyes.
v) A rash that is itchy and spreading.
vi) If suffering from any communicable disease.
vii) Recovering from any surgery / major injury
PARENTS ARE ADVISED TO ENSURE THAT THEIR CHILD JOINS THE SCHOOL ONLY AFTER
COMPLETING THE INCUBATION PERIOD AND OBTAINING A MEDICAL FITNESS
CERTIFICATE FROM A CERTIFIED MEDICAL PRACTITIONER.
It is only ‘Sound Health’ that promotes overall well-being of a child. With a view to minimizing reaction
time in providing emergency medical assistance to students who require such help, it is imperative that
the school has data regarding such cases.
Parents of children with health-related issues are requested to fill the attached Medical Alert Form
regarding the state of health of their wards and submit it to the respective Class Teachers.
Please note, if your ward is a part of SCHOOL SPORTS TEAM, but is suffering from any contagious
disease, the participation of the student will be permissible only if the School Doctor clears the student
for participation. No student will be allowed to participate in SPORTS until medically cleared by the
School Doctor.
In the event of a serious accident, an emergency service will be arranged at once and the parents will
be contacted immediately. A member of the teaching staff, usually Home Room Teacher will
accompany the casualty to the Hospital Emergency Department. In less serious cases, parents will be
requested to collect their child from the school and arrange for further treatment.
It is important for parents to inform the school of any changes in their emergency contacts
and also furnish particulars of the person who will be responsible for their child, if parents
are out of NOIDA.
Please find attached the Medical Alert form to be filled in by each parent for the information of school.
Wishing all Bal Bharatians the very pink of health !

Encl. : As Above Asha Prabhakar

(Principal)
 MEDICAL ALERT FORM
Please read the instructions given below carefully. Feel free to contact the school if you need any
clarifications.

This document contains SIX pages as we have combined all FOUR medical forms into one to make it
easier for parents to find them and fill them out. This ensures that the school has all necessary forms
completed to maintain a safe and efficient process for all students.

Complete only the appropriate form(s) and submit them as soon as possible to comply with the School
Health Policy.

Instructions :

• Read the description for each form and choose which applies to your child.
• Indicate which form(s) you need to complete by selecting the checkbox next to that form.

CHECKBOX FORM NAME DESCRIPTION PAGES

Select all that applies Click on form button to access from

Complete this form if your child

has a medical condition that needs
Medical Alert Form 1 to 2
precautionary treatment or
medication at school
Complete this form ONLY if your
Request for Administration of
child needs medication 3
medication
administered at school.

Vaccination form Complete this form ONLY if your

(Mandatory for all PS & PP child needs an anaphylaxis 4
parents to fill) emergency action plan*

Complete this form ONLY if your

General Health Form child needs a diabetic action plan* 5 to 6
at school

(The information collected on this form is subject to and protected by the provisions of the Freedom of
Information and Protection of Privacy Act).

Medical Alert Form School Year :

Student ‘s Name:
Class :
Photo ID
Section:
Date of Birth:

Age

Contact Name & Telephone Numbers

Mother’s / Guardian’s Father’s / Guardian’s

Name : Name :

Father’s/Guardian’s Mother’s/Guardian’s
Land line Office or Mobile No Office or Mobile No

Page 1 of 6
 Physician’s Phone Number
Name
Indicate what medical condition the student has that may require emergency care at school :

Describe the potential problem (include symptoms that might be observed)

Describe the necessary action or intervention to appropriately treat this medical condition :

Step 1

Step 2

Step 3

Step 4

Step 5

Is medication needed?

If yes, what medication?

Prescribing Physician : Phone No

Parents must complete a Request for Administration of Medication Form (section below) if their
child needs medication administered at school in case of an emergency.

Note : No medication will be administered until this section of the medical form is
completed. Parents need to ensure that the medication does not expire. It is the
obligation of parents to keep a sufficient supply of any required medication at the
school.

I have read and verified that the above information is correct.

Parent’s / guardian’s Name Signature Date

Copy to:

Student’s Dossier File

Medical Bay

Page 2 of 6
 REQUEST FOR ADMINISTRATION OF MEDICATION
Complete this section ONLY if your child needs medication administered at school.

If changes occur I will contact the school and provide revised instructions. I am aware I
am required to update this information each April.
I request that staff give medication as prescribed on this form to my child in case of an
emergency.
I agree to supply the medication to the school in the original container with the child’s
name, prescribing physician’s direction for use including dosage.
I am aware that the Doctor and Nurse for the school will be informed of my child’s condition
and medication; and that the Nurse may contact me as necessary.
I am aware that staff and other personnel working with my child will need to know my
child’s condition and the medication required.

If training is required to administer the medication, please specify,

Training on :

Trainer’s Name Training Date

Name of Trained Name of Trained
Person 1 Person 2

Authorization – I agree to (select those that apply) :

Supply the school with medications and up-to-date Epi-pen(s) /Inhaler

Provide the child with a medic alert bracelet and fanny-pack for Epi-pen/Inhaler

Ensure the child knows his/her responsibilities for his / her own safety

Ensure the child will have an Epi-pen /Inhaler on their person. (It is strongly recommended
that children have Epi-pens on their person at all times)
I understand that my failure to do the above may result in an inability to implement timely
emergency procedures for this potential life threatening condition.
I authorize the staff of BBPS Noida to execute the school’s commitments as outlined within
this plan.
I am aware that the Doctor and Staff Nurse of BBPS (Noida) will be informed of my child’s
condition and treatment and that the Nurse may contact me as necessary.
I give consent for the identification of the child as a person with _________________
(nature of condition / risk).
I understand that this may include the display of pertinent information, including a picture
of the child in strategic locations within the school. It is understood that the person for
this display is to enable the Staff of BBPS Noida to respond to potential emergencies in a
timely fashion. It is clearly understood that student confidentiality will be maintained
wherever possible.

Parent’s / guardian’s Name Signature Date

Page 3 of 6
 [To be submitted at the time of admission of the student]

VACCINATIONS

Name of the Student ...................................................................................................................

M/F ………….…….............Class..........................Section…………………

Date of Birth ................................................................ Blood Group .........................

RECEIVED
IMMUNIZATION AGE RECOMMENDED
YES NO
BCG 0-1 Month
At Birth
Hepatitis B 1 Month
6 Month
2 Months
DPT 3 Months
4 Months
2 Months
HB 3 Months
4 Months
At Births
1 Months
Oral Polio 2 Months
3 Months
4 Months
Measles 9 Months
MMR 16 Months
DPT+OPV+HIB 18 Months
Typhoid 2 Years
Hepatitis A (2 Doses) 2 Years
Chicken Pox After age 1 year
DT – OPA 4½ Year

BOOSTER DOSES

Typhoid DATE DATE DATE

(Every 3 years)

TT (Every 5 years)

Other Vaccines

Signature of Father .............................................Signature of Mother ...........................

Page 4 of 6
 GENERAL HEALTH FORM

TO BE CERTIFIED BY A REGISTERED MEDICAL PRACTITIONER

Name of the Student …………………………………………Class ………………..Academic Year ………..

Date of physical examination........................Height ………..…….Weight....……......BMI ..........

B.P.............................. Pulse …………….......... Vision (L) ………........ (R) .......................

Squint.................... Conjunctiva……………........ Cornea……...........Ear L............ R............

CLINICAL
NORMAL RECOMMENDATION REMARKS, IF ANY
EXAMINATION

Head/Neck

Abdomen

Surgery

Serious Illness

Nails

Skin

Summary of Current Health Condition :

___________________________________________________________________________

___________________________________________________________________________

Fit to Participate in all age specific physical activities including Swimming

___________________________________________________________________________

Fit to participate in age specific physical activities with precautions

___________________________________________________________________________

___________________________________________________________________________

Should not participate in competitive sports / activities involving a lot of physical activity

___________________________________________________________________________

Signature of Doctor ……………………

Name of the Doctor……………………

Major Vaccines Received

BCG Oral Polio Cervical/Pineal

DPT Covid 19 Hepatitis -B

MMR TT

Page 5 of 6
 HIGH BLOOD SUGAR SYMPTOMS My child’s symptoms at time of HIGH blood sugar reaction are usually :

Headache Frequent urge to urinate Excessive thirst

Drowsiness Nausea / stomach pain Dry mouth

Behaviour Change

Others (Please Specify)

Epilepsy Over Weight

Allergy Under Weight

Asthma

HIGH BLOOD SUGAR TREATMENT

If blood sugar is low /high : Notify the parents

The school is not responsible for administering insulin

Authorization – I agree to (select those that apply) :

Provide emergency sugars and snacks for the treatment of low blood sugar.

Keep a glucometer and adequate supplies for the monitoring of blood sugar levels for my child
and ensure child is aware of safe disposal of sharps and supplies.

If changes occur, I will contact the school and provide revised instructions. I am aware I am
required to update this information as needed.

I am aware that the Doctor and Staff Nurse of BBPS (Noida) will be informed of my child’s
condition and treatment and that the Nurse may contact me as necessary.

I authorize the staff of school to execute the school’s commitments as outlined within this
place.
I give consent for the identification of the child as a person ______________________ (nature
of condition / risk). I understand that this may include the display of pertinent information,
including a picture of the child, in strategic locations within the school. It is understood that
the reason for this display is to enable the staff to be able to respond to potential emergencies
in a timely fashion. It is clearly understood that student confidentiality will be maintained
wherever possible.
I authorize the staff of BBPS (Noida) to administer the designated treatment and to provide
suitable medical assistance. I agree to bear all costs associated with the medical treatment of
my ward and absolve BBPS (Noida) and the Child Education Society of the responsibility for
any adverse reactions resulting from the administration of the designated medication.

Parent / Guardian Name Signature Date

Page 6 of 6