# Consent Form for Medical Issues

## Part 1: Student Information

Student’s Full Name:
Emirates ID Number*:

In the unlikely event that a student has a medical dilemma or emergency during the program, Rize Enrichment Programs staff request permission to administer any and all necessary medical aid including transport to nearest medical facility.

By signing below, I agree to the following:

- I agree to my child receiving medical treatment and examination as required.
- In the event of an accident or other medical emergency in which I cannot be contacted in a timely manner, I authorize Rize Enrichment Programs staff to take appropriate medical action to ensure the health and well-being of my child.
- I agree to disclose, to the best of my knowledge, my son or daughter’s complete medical history in the sections that follow. I also agree to provide comprehensive documentation of my son or daughter’s vaccination history when submitting this consent form.
- I agree that Abu Dhabi Department of Education and Knowledge (ADEK) shall not be liable for any resulting legal compensation, in the event that I fail to provide correct or incomplete information about the Participant's status or non-compliance with the Terms and Conditions of Rize Enrichment Programs, and I agree in this case that Abu Dhabi Department of Education and Knowledge (ADEK) has the right to cancel or remove participants from the program.

I confirm all above information

## Medical History

Please indicate below if your child suffers from, or has suffered from, any of the following:
Medical History/ Past & Present
Yes
No
If “Yes” please provide details
Asthma
If “Yes” please provide details
Epilepsy
If “Yes” please provide details
Chicken Pox
If “Yes” please provide details
Measles
If “Yes” please provide details
Physical Disability
If “Yes” please provide details
Hearing Ailments
If “Yes” please provide details
Eczema/Psoriasis
If “Yes” please provide details
Heart Disorders
If “Yes” please provide details
Diabetes
If “Yes” please provide details
Visual Impairment
If “Yes” please provide details
If you have indicated that your child has any of the above, please provide more details, including any medications he or she has been prescribed:
Does your child have any known allergies? If so, please describe:
Has your child ever had an infectious disease (e.g. hepatitis)? If so, when?
Has your child ever undergone a surgical procedure? If so, please give details:
In the event of a medical emergency related to any pre-existing conditions your child may have, please provide any necessary details for Rize Enrichment Programs staff in order to best treat your child.
Is there anything ADEK should know regarding your child’s health that is not mentioned on this form? If so, please describe:
I confirm all above information

I, and on behalf of my family and minors, appreciate and fully accept the risks associated with visiting various locations and participating in activities and hereby:

- Release Abu Dhabi Department of Education and Knowledge (ADEK), its officers, employees and contractors from any and all liability, claims, or causes of action that I have, or may have, against it including, without limitation, those in respect of loss or damage to property, or in respect of personal injury or death.
  And
- Indemnify Abu Dhabi Department of Education and Knowledge (ADEK) against any and all costs, losses, expense or damage, including without limitation, claims by any person for loss or damage to property or in respect of personal injury or death arising from, in connection with or relating to my attending any of the activity locations, participating in activities, and (where applicable the attendance of minors (under the age of 18 years))

Please note that in signing this form you are agreeing to the terms and conditions of entry and participation; failure to sign will deny participation in any of the available activities.

STUDENT’S FULL NAME & SIGNATURE
DATE: