Form 11-2018 To be signed by a Medical Doctor. 3 copies: original for accompanying adult, one for host school, one for host family. Keep a copy at school.

 

INTERNATIONAL SCHOOL-TO-SCHOOL EXPERIENCE

 PHYSICAL EXAMINATION 

Name of child: _________________________________________________________

Blood Type _____________ Height ____________ Weight ______________

S- Satisfactory                        NS- Not Satisfactory                N/A- Not applicable

General Condition __________

Posture and Spine__________

Feet __________

Skin __________

Eyes (Vision) __________

Nose __________

Ears (hearing) __________

Throat/tonsils __________

Teeth __________

Heart __________

Lungs __________

Abdomen __________

Allergies __________

Blood Pressure _____________________

Normal body temp (F) ____________

Other? ________________________________________

I believe that, ___________________________, is able to participate in the International School to School Experience program and all of it activities except the following: __________________________________________________________ (if none, please write none.)

Signature of examining physician ________________________________________

Office _____________________________________

Address _______________________________

Office phone number ______________________________

Date ___________________________________