COVID-19 HEALTH DECLARATION FORM

(For parents)

All children and parents that are returning to centre shall finish all the information required in this
form.

PART A - Basic information

Child’s name
ID No Nationality
Father's name Phone Number
ID No Nationality
Mother's name Phone Number
ID No Nationality
Address
Guardian's name Phone Number
ID No Nationality
Other Address
* Definition other address is another address (guardian's address) that your child stayed at during MCO period besides
of the main address

PART B – Declaration

Health condition (Any symptoms over the past 14 days?)

Name Age Sore Difficult
Fever Cough Others
throat breathing

*) Please fill in above information for all family member that stay in the same house

1. Is anyone in the family have travelled to other countries during the MCO period.
Yes No
2. Did anyone in the family stay at other address (hometown) during MCO period?
Yes No
If your answer for 2nd question is yes, please stated the type of transportation that he used to
travel.
Own car Public transport Others _______________
3. Did anyone in the family stay with other relatives or friends from different address during
MCO period?
Yes No
4. Have anyone in the family been in close contact with a person suspected to have COVID-19?
Yes No

COVID-19 Health Declaration Form (for parents)

 If the answer is YES to either of the questions above, you (and all family member) are required
to self-quarantine 14 days before attending school.

*) Definition close contact:

• Health care associated exposure, including providing direct care for COVID-19 patients, working with health care
workers infected with COVID-19, visiting patients or staying in the same close environment of a COVID-19 patient.
• Working together in close proximity or sharing the same classroom environment with a with COVID- 19 patient
• Traveling together with COVID-19 patient in any kind of conveyance
• Living in the same household as a COVID-19 patient

Hereby, I declare that anything contained therein is true and correct. I understand that any of the
information I have provide or this verification is incorrect, incorrect or counterfeit, I may be
subject to action under any law. I promise to fill out new COVID-19 health declaration form if any
of the above information changes after today. This declaration was made by:

________(Signature)__________ Date: _____________________

Name: _________________________ ID No: ____________________

COVID-19 Health Declaration Form (for parents)