DOUGLAS MEMORIAL HIGHER SECONDARY SCHOOL

52, Barrack Road, Barrackpore, Kolkata – 700120

Ph. No. 08448449503, 033-25920450

Due to the ongoing and rapidly changing situation with the novel-coronavirus
(COVID-19), we are requiring all our students of Douglas Memorial Higher
Secondary School to fill-out the self-declaration form below. School Management will
make a decision on access to the school based on the answers provided below.

Each student must complete this form and submit it to the school office prior to the
school visit.

First Name

Last Name

Email

Phone number

Class

Section

1. Do you have any of the following flu-like symptoms:

If one of the 4 symptoms is present you cannot come to the school

Fever (37.5° or higher) ⬜ Yes ⬜ No

Cough / Cold ⬜ Yes ⬜ No

Breathlessness ⬜ Yes ⬜ No

Loss of smell and/or taste ⬜ Yes ⬜ No

Others : Please specify

2. Please list the country/cities you have travelled to in the last 14 days prior to
arriving at the school.

Name of
Country/City

Date of arrival

Date of departure
 DOUGLAS MEMORIAL HIGHER SECONDARY SCHOOL
52, Barrack Road, Barrackpore, Kolkata – 700120
Ph. No. 08448449503, 033-25920450

By signing this self-declaration form, I confirm that I have not tested positive for
Covid-19 in the last 14 days or been required to be in a quarantine during the last 7
days.

This document will be retained confidentially by the school for one month
after submission.

The health and wellbeing of our community is our first priority therefore school
management reserves the right to deny entry to the campus.

Signature of the student :

Signature of the guardian :

Date:

***********************************************************************************************
Private Data Protection notice:

This data sheet will be stored in our school and is not shared with any third party,
unless there will be an official request by the local authorities for reasons of public
interest in the area of public health.

The datasheet will be deleted one month after collection, unless a longer period
is required by the public authorities.

Thank you for your cooperation.

 DOUGLAS MEMORIAL HIGHER SECONDARY SCHOOL
52, Barrack Road, Barrackpore, Kolkata – 700120
Ph. No. 08448449503, 033-25920450

Due to the ongoing and rapidly changing situation with the novel-coronavirus
(COVID-19), we are requiring all our teachers/staff of Douglas Memorial Higher
Secondary School to fill-out the self-declaration form below. School Management will
make a decision on access to the school based on the answers provided below.

Each teacher/staff must complete this form and submit it to the school office prior to
the school visit.

First Name

Last Name

Email

Phone number

Whom to contact in
emergency

1. Do you have any of the following flu-like symptoms:

If one of the 4 symptoms is present you cannot come to the school

Fever (37.5° or higher) ⬜ Yes ⬜ No

Cough / Cold ⬜ Yes ⬜ No

Breathlessness ⬜ Yes ⬜ No

Loss of smell and/or taste ⬜ Yes ⬜ No

Others : Please specify

2. Please list the country/cities you have travelled to in the last 14 days prior to
arriving at the school.

Name of
Country/City

Date of arrival

Date of departure
By signing this self-declaration form, I confirm that I have not tested positive for
Covid-19 in the last 14 days or been required to be in a quarantine during the last 7
days.

This document will be retained confidentially by the school for one month
after submission.

The health and wellbeing of our community is our first priority therefore school
management reserves the right to deny entry to the campus.

Signature of the teacher/staff :

Date:

***********************************************************************************************
Private Data Protection notice:

This data sheet will be stored in our school and is not shared with any third party,
unless there will be an official request by the local authorities for reasons of public
interest in the area of public health.

The datasheet will be deleted one month after collection, unless a longer period is
required by the public authorities.

Thank you for your cooperation.

 CONSENT LETTER

I, ___________________________, father / mother / guardian of

__________________________ from class ________ hereby give my
consent to send my ward to school from 12th February, 2021 as per the
government directive passed on 4th February, 2021.
I am also convinced that school shall not be liable towards any unforeseen
health condition of my ward during this phase of Covid–19.
I give this consent with free will and out of no compulsion.

Signature of Parent/Guardian