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School Clinic Immaculate Conception College of Balayan, Inc.

Student Health Information Form

Please fill in this form so the school clinic has the health details it needs to care for the student. A parent or guardian should fill it in for younger students.

Fields marked are required. Clinic staff review every form before it is added to the clinic records.

Student information

Name and details as they appear on school records.

Leave empty only if unknown.
School ID or LRN.

School details The choices follow the category. Leave them empty for employees and visitors.

Contact and address

How the clinic can reach the student or the family.

Home address
Pick the region first, then province, city and barangay.

Parent or guardian

Needed for students who are minors. Optional for others.

Parent or guardian address
Pick the region first, then province, city and barangay.

Health information

Leave a box empty if there is nothing to report.

Consent

Please read this statement before sending the form.

I confirm that the information I give is true and complete. I agree that the school clinic may collect, store and use this information to provide health services, contact my parent or guardian, and keep clinic records, in line with the Data Privacy Act of 2012 (Republic Act No. 10173). I understand that only authorized clinic staff can view it and that I may ask the clinic to correct it.

Tick the consent box to send the form.