/SSE-medical-form

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.