Professional Documents
Culture Documents
Home Country____________________
(Give original to your US host family, make 2 copies- give to the Director at your US arrival orientation site & AFS Office in your country)
Weight_________
Pulse ____________
1) Has participant had a substantial weight loss since completion of YES application?
Yes [ ] No [ ]
If yes, why?
_______________________________________________________________________________________________________
2) Has participant been hospitalized since completion of the YES application?
Yes [ ] No [ ]
If yes, when, why and outcome:
_______________________________________________________________________________________________________
3) Is the participant currently on medication?
If yes, why, name of medication, dosage, frequency
Yes [ ]
No [ ]
_____________________________________________________________________________________________________________________
Dy/Mo/Yr
Dy/Mo/Yr
Dy/Mo/Yr
Dy/Mo/Yr
Measles
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Mumps
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Rubella
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Diphtheria
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Pertussis
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Tetanus
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Hepatitis A
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Hepatitis B
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Polio
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Varicella
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BCG
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TB Test
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Yes [ ]
No [ ]
Dy/Mo/Yr
Date ____________
Result
____________
Date ____________
Result
____________
I, the undersigned, certify that all important recent medical information has been included, that nothing relevant has been omitted
and that the participant is able to travel abroad.
Physicians Name: _________________________________________________ Address:
____________________________
Signature:
_________________________________________________ Date: ________________________________
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C) PARENTS, please complete this section: In the event of a medical emergency we, the natural parents of the participant,
authorize the YES hosting organization to obtain emergency medical treatment if required by a situation due to an accident or
unanticipated illness. Authorization is also given for immunizations and x-rays.
We are also aware that due to some USA state school requirements students may be required to receive additional vaccines
before registration and at the cost of the participant.
2 April 2010