Student Health Form

As part of the Admissions process, we ask you to complete this form. 

This information will be sent to and used by ASH Health Services. When you come for your Intake Visit you will meet with the nurses, and have the opportunity to further discuss any health issues. Please bring your child's vaccination records with you when you come for your Intake Visit.

The Nurses's Office is happy to provide your child with general health care during the school day. Having adequate and up-to-date information about your child's health is crucial to our ability to provide this care. Therefore we kindly ask you to complete all sections of this student health form.

*Fields marked with * are mandatory.
Student Information
MM/DD/YYYY Please use this format
Elementary, Middle, High
06. Daily Medications (at home or at school). Please specify the medication, the dosage and times given, and if needed at school.
NOTE: Please type in one continuous line - please do not press "enter" to write on separate lines.
May the school nurse give your child an aspirin substitute?(e.g. Tylenol, Paracetamol, Panadol)
Does your child wear glasses or contact lenses?
Has your child been vaccinated?
If NO, please note that during your meeting with the school nurse, which must take place before your child(ren) starts school, a conversation will be had regarding the standards and recommendations of immunization policies for The Netherlands. (You may need to enter n/a into any required fields.)

If your child has been vaccinated you must enter all the immunizations received to date. Receipt of vaccination records does not replace the need to complete this form.
IMMUNIZATION RECORD - Date each dose was given
DTaP - diphtheria, tetanus, pertussis (given in the US)
DKTP - Diphtheria, Kinkhoest (pertussis), tetanus, polio (given in the Netherlands)
MM/YYYY Please use this format for all dates below
Polio: IPV- Inactivated polio vaccine, or given as part of a combined vaccine such as DKTP
MM/YYYY Please use this format for all dates below
(additional to above) MM/YYYY
MM/YYYY Please use this format
DT- tetanus,diptheria toxoid
(additional to above) MM/YYYY
MMR or BMR- measles, mumps, rubella
MM/YYYY Please use this format for all dates below
Hib- Haemophilus influenza type B
MM/YYYY Please use this format for all dates below
Hepatitis B - HBV
MM/YYYY Please use this format for all dates below
Hepatitis A
MM/YYYY Please use this format for all dates below
MM/YYYY Please use this format for all dates below
Varivax- Varicella (chickenpox)
MM/YYYY Please use this format for all dates below
MM/YYYY Please use this format for all dates below
Meningitis - Meningitis C - MCV - Meningococcal - ACYW
MM/YYYY Please use this format for all dates below
PCV- Pneumococcal conjugate vaccine
MM/YYYY Please use this format for all dates below
HPV - Human Papilloma virus
MM/YYYY Please use this format for all dates below
Other Immunizations
MM/YYYY Please use this format for all dates below
MM/YYYY Please use this format for all dates below
MM/YYYY Please use this format for all dates below
MM/YYYY Please use this format for all dates
Please click SUBMIT to send these details to us. Bring your child's vaccination records with you when you come for your Intake Visit.
University preparatory program for ages 3-18. Fully accredited by the Council of International Schools and the Middle States Association of Colleges and Schools.

American School of The Hague