*Current Grade: *Grade Applying for: *Registration Number: *Health book number:
*- Required field
Updated/Approved April, 2017 Application, Page 1 of 6
School Administration
Zaisan Hill 11, Khan Uul District
School Phone: (976-11)341501
Fax: (976-11)345359
www.asu.edu.mn
Father Mother
Emergency Contact
Do you have any concerns that you would like to discuss with the:
Name: Grade:
Please check any of the following conditions which currently affect your child:
Any medication
(*Students requiring medication at school MUST have parents written note)
Please check if your child has had any of the following diseases:
History of Immunization
I will inform the school of any changes in the above information. I understand that if my child
contracts an infectious disease or condition I will inform the school and withdraw my child until
he/she is no longer infectious
Notified by
Date Date Testing Starting
Admitted Grade Student ID Student
Received Tested time Date
Services Office
Yes/No
NOTES /
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