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HEALTH INFORMATION Confidential
Please complete ALL relevant sections of this form and email Immunity card to:
immunitystatus@ajhs.school.nz
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* Indicates required question
Email
*
Your email
Student Surname
*
Your answer
Student First Name
*
Your answer
Enrolling for (Year)
*
2024
2025
Other:
Year Level
*
7
8
9
10
Date of Birth
*
MM
/
DD
/
YYYY
Parent/Caregiver name
*
Your answer
Parent/Caregiver home phone no.
*
Your answer
Parent/Caregiver work phone no.
*
Your answer
Parent/Caregiver mobile phone no.
*
Your answer
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