MEDICAL FORM
TO BE COMPLETED BY PARENT (Parent signature required)
STUDENT NAME: DATE OF BIRTH:
(Family) (First) (Middle) Month / Day / Year
SEX: M F GRADE/YEAR: SCHOOL: ASD BSD ISG DAMMAM ISG JUBAIL SVS
VACCINATIONS REQUIRED FOR ADMISSION TO ISG
Please submit a copy of your child’s vaccination record(s) reflecting these requirements:
z At least 4 doses DTaP (the last dose at age 4 or older)
z At least 4 doses polio (IPV or OPV) (the last dose at age 4 or older)
z 2 doses MMR (measles/mumps/rubella)
z TB skin test/PPD in past 12 months or history of BCG
z MCV4 vaccine in past 5 years (quadrivalent meningitis vaccine)
z Hep A vaccine (2 doses)
z Hep B vaccine (3 doses)
z Varicella vaccine (2 doses) or proof of disease history
Please note that the above required ISG enrollment vaccines may be over and above what is administered in your home country or current
country of residence. These vaccines may also be required earlier than the vaccination schedule of your home country or current country of
residence. However, they are in line with the Saudi vaccination schedule.
I hereby certify that I have read, understand and agree to the policy.
Printed Name of Parent/Guardian Signature of Parent/Guardian Date
TO BE COMPLETED BY PHYSICIAN (Physician signature required)
Does the above-named student have a history of:
YES NO YES NO
Measles Skin Problems
Mumps Seizures
Rubella Hearing Problems
Chicken Pox Vision Problems
Asthma Surgery
Other serious illness:
Based on information above and a physical examination, I find the above-named student fit for all usual school activities.
Signed: MD/NP/PA Date:
Physician or Clinic Stamp (required):
This form may be signed and stamped by a physician in KSA or abroad.
