Icsv.at

PRIMARY CONTACT INFORMATION
Date _____________________________ Grade Level________ Student __________________________________________________ Date of Birth________________ Address_________________________________________________________________________________ ___________________________ __________________________ _________________________ Father’s Cell Phone/Handy Mother’s Cell Phone/Handy
SECONDARY CONTACT INFORMATION
If parents are not available, in case of emergency, please call: 1st Contact _______________________________________________________________________________ _______________________________________ _____________________________________ _______________________________________ ______________________________________ _______________________________________ _____________________________________
DOCTOR INFORMATION:
_________________ _______________________________________ _______________________
RELEASE OF LIABILITY
The faculty of ICSV has my permission to deal with any medical emergency which may arise while my child is in their care. Parent Signature _______________________________________________

CONSENT FOR ASPIRIN SUBSTITUE:
I give permission for my child to receive aspirin substitute ( Ibuprofen, paracetamol) from the office for headaches or
other minor discomforts.
Parent Signature_______________________________________________
Parent Signature_______________________________________________
(PLEASE COMPLETE OTHER SIDE)
Phone: 43 (1) 25122 • Fax: 43 (1) 25122 518 • E-Mail: office@icsv.at • Web Site: www.icsv.at
IMPORTANT IMMUNIZATION INFORMATION
FOR FURTHER QUESTIONS PLEASE CONTACT US.
According to ICSV school policy, each student is required to provide an up-to-date record with
all required vaccinations including the date and signature of health worker who verified the
record.
*A current Tuberculosis test and verification is required for students that have moved to Vienna within the past 6 months.
* If you need any Vaccinations those are avalible through the general practitioner and not through the school doctor here at ICSV. Name of Immunization
Date of First
(Auffrischungsimpufung)
(Auffrischungsimpufung)

REQUIRED
DTaP
Hib (Haemophilus Influenzae)

IPV
Polio (shot)/Kinderlamung Impfung __________________ __ __________________ _________________
__________________ __ __________________ _________________
__________________ __ __________________ _________________
__________________ __
__________________
_________________
Allergies/Allergien
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Regular Medication
(Including Ritalin / Concerta or similar Medication for ADHS) __________________________________________________________________________________________________
__________________________________________________________________________________________________
Chronic diseases
(Please Include Diabetes, Phenylketonuria (PKU), Asthma…) __________________________________________________________________________________________________
__________________________________________________________________________________________________
Physician’s Signature________________________________________ Date ________________________________
Phone: 43 (1) 25122 • Fax: 43 (1) 25122 518 • E-Mail: office@icsv.at • Web Site: www.icsv.at

Source: http://www.icsv.at/wp-content/uploads/2011/05/Medical-and-Emergency-Info-new.pdf