DOCTOR’S CERTIFICATE

(Please have this form filled up by your Paediatrician/General)

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

Age ………….. Gender ………………..

Weight ……….

Ophthalmic Problems ………………………………………………………………………………………………..

Dental Check-up Report ……………………………………………………………………………………………..

Orthopaedic Problems ………………………………………………………………………………………………

Respiratory Problems ………………………………………………………………………………………………...

Skin Problems …………………………………………………………………………………………………………

Allergies ………………………………………………………………………………………………………………..

Food Allergies………………………………………………………………………………………………………….

Epilepsy ………………………………………………………………………………………………………………..

Metabolism (Obesity etc) …………………………………………………………………………………………….

Heart Problems ………………………………………………………………………………………………………..

Any other problem

………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………

I have examined the child and have found [him/her] to be in good health and free from any communicable diseases.

The child has been vaccinated against common communicable diseases such as measles, mumps, rubella, and
chickenpox, in accordance with government laws.

The child does not have any known medical conditions that would pose a risk to [him/her] or other students in a
school environment.
I have reviewed the child's medical history and confirmed that [he/she] has no allergies or medical conditions that
require special accommodations or restrictions. I have also reviewed the child's immunization records and verified
that they are up-to-date.

I hereby authorize …………………………………………………………..to attend RP Goenka International school and

participate in all academic and extracurricular activities.

Doctor’s Name …………………………………………………………

Signature with stamp

Registration Number

Date of Examination