HEALTH DECLARATION FORM Page 1 of 3

Thy Covenant Montessori School

Senior High School Department
#98 R. Magsaysay St. Phase II, AFPOVAI, Fort Bonifacio, Taguig City
Tel No. (02)-88923-1302

For the School Year 2022-2023, in lieu of the course program of Physical Education and Health of Thy
Covenant Montessori School’s (TCMS) Senior High School Department (SHS), students are required to
complete the Health Declaration Form for admission. This form will be part of your medical records as a
student and will be treated with utmost confidentiality. Please type or write in black or blue ink only and
submit to your respective adviser.

Student’s Name: ________________________________________________

Last First Middle Attach a recent 2x2
Gender: _________ Year & Section: _______________________________ photograph here.
Phone #: ____________________ Cellphone #: ______________________
Home Address: _________________________________________________
______________________________________________________________
Date of Birth: ___________________________ Nationality: __________________________
Month Day Year
Father’s Name: ____________________________ Contact #: ____________________________
Mother’s Name: ____________________________ Contact #: ___________________________
Alternate person(s) to contact in case of emergency:
Name: _______________ Relationship to the Student: ____________ Contact #: ____________
Name: _______________ Relationship to the Student: ____________ Contact #: ____________

HEALTH HISTORY
1. Does your child have an illness or condition (heart condition, seizures, etc.)?
_____ Yes _____ No If yes, explain: __________________________________________

2. Does your child have a suspected or diagnosed special need (ADD, autism, speech delay,
etc.)?
_____ Yes _____ No If yes, explain: __________________________________________

3. Does your child have any allergies (to medication, food, pets, etc.)?
_____ Yes _____ No If yes, explain: __________________________________________
HEALTH DECLARATION FORM Page 2 of 3

4. Does your child receive any medication or medical treatment, either regularly or
occasionally?
_____ Yes _____ No If yes, explain: __________________________________________

5. Has the child been hospitalized for any reason?

_____ Yes _____ No If yes, explain: __________________________________________

If a doctor prescribes any recommendations regarding your child’s health, please submit a copy
of the recommendation orcertificate to the school as soon as possible – to the respective class
adviser. Otherwise your child will be considered “Physically Fit” and able to participate in
Physical Education (P.E.) activities required by the curriculum and in other activities that may be
part of the school program. Therefore, TCMS shall NOT be held liable for any further medical
concerns that may arise which may lead to including but NOT limited to death. Thank you.

AUTHORIZATION
I give consent for my child recive the following:
1. Minor first aid by the nurse at the school clinic (medication and treatment).
______ Yes _______No
2. Transportation to the hospital of the school’s choosing, in severe cases or an emergency.
______ Yes _______No

NOTE: If you checked “NO” to either number 1 or 2 please provide an alternate care
instructions by attaching an additional page of information. And please bear in mind that TCMS
shall NOT be held liable for any medical concerns further arise which may lead to including but
NOT limited to death.Thank you.
HEALTH DECLARATION FORM Page 3 of 3

DECLARATION AND DATA SUBJECT CONSENT FORM

I certify that the above history is true to the best of my knowledge. I have fully disclosed all medical
conditions that may affect the performance of my child as a student of TCMS. In compliance with the
Data Privacy Act of 2012 and its Implementing Rules and Regulations, I voluntarily consent to the
collection, processing, and storage of my child’s personal and health information for the purpose/s of
health information of the SHS Faculty of TCMS. I also understand that every effort will be made to notify
parents in the case of an emergency.

_________________________________________ ________________________
PARENT’S SIGNATURE OVER PIRNTED NAME DATE

_________________________________________ ________________________
STUDENT’S SIGNATURE OVER PIRNTED NAME GRADE & SECTION

Note: If you disagree with the above statement and prefer not to sign, please provide an
explanation and alternate care instructions by attaching an additional page of information.
Thank you