MEDICAL FORM SECONDARY SCHOOL EXCHANGE SCHOLARSHIP
To be completed by the parent(s)/guardian(s)
This form provides the American/Canadian schools with full medical information to enable them to watch the scholar’s health for the duration of his/her stay overseas. Name:
Date of birth:
Name of parent(s)/guardian(s): Address:
Home tel: Height:
Work tel: m
cm
Weight:
Have the scholar's tonsils and/or adenoids been removed:
kg
Yes/No
If so, when?
Are there any details you feel an American/Canadian school should know about your son’s/daughter's diet, wellbeing, etc?
Please tick the boxes as applicable:
Illnesses suffered
Chronic or Recurring Conditions
Scarlet fever
Ear Infections
Diphtheria
Hard of Hearing
Measles
Seizures/spells
Mumps
Kidney Disease
German Measles
Sickle Cell Anaemia (not trait)
Whooping Cough
Head, spinal cord injury, or disease of central nervous system
Chicken Pox
Eye diseases Heart Disease Asthma Diabetes Other (please list):
Signed (parent/guardian)
Date
Name (in block capitals) Please note that a further medical form will need to be completed by the applicant’s GP if the applicant is successful in being awarded a scholarship.