2020/21 Student Travel History and Health Status Declaration Form

2020/21 Student Travel History and Health Status Declaration Form

2019 Coronavirus Disease (COVID-19)
This form is to be completed by a parent/legal guardian and on behalf of the family.

A confirmation email with an attachment of the information provided will be sent to you upon submission.

Persons dropping off and/or picking up your child(ren) from the School must present a copy of the attachment before entering the premises.

Should there be any changes to the information provided, please update the School Office (email office@smallworld.edu.hk or call 255 0922) immediately.
Child 1 Full Name*

First NameLast Name
Class*
Gender

FemaleMale
Child 2 Full Name (if applicable)

First NameLast Name
Class
Gender

FemaleMale
Child 3 Full Name (if applicable)

First NameLast Name
Class
Part A - Travel history of your child(ren) outside HK in the past 14 days*

My child(ren) have not been away from Hong Kong in the past 14 days prior returning to school premises.My child(ren) have paid visit outside Hong Kong in the past 14 days prior returning to school premises.
Duration: From Date* (Departure date) To Date* (Arrival date)
Destination (Please specify countries and cities) : *
Part B - Whether your child(ren) have confirmed infection of COVID-19*

My child(ren) have not confirmed infection for COVID-19.My child(ren) have confirmed of COVID-19 infection and have already recovered.
Hospitalization Period: From Date* To Date*

Part C - Health status of those taking care of or those living with your child*

	Full Name	Relationship to your child(ren) (e.g. Grandparent, Helper)	Away from HK in the past 14 days	Infection of COVID-19*
1
2
3
4
5
6

* In general, close contact means having cared for, having lived with, or having had direct contact with respiratory secretions and body fluids of a confirmed patient.
Part D - Current health status of the Student(s)

My child(ren) have no symptoms of cough, shortness of breath, breathing difficulty and sore throat.
Contact Details of Person filling in the form
Full Name*
e.g. John Smith
Email*
e.g. j.smith@smail.com
Relationship to the Student(s)
e.g. Father, Mother, Legal Guardian
Signature*

Clear
School Email
example@example.com
Should be Empty: