General Health Information and Medical History 2020
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Full Name *
Date of Birth *
MM
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DD
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Please check the appropriate box(es) to indicate if you have (or had) the following medical conditions: *
Please check all that apply.
Required
Please list dates and important information for any medical condition indicated above. *
Please explain which conditions should be taken into consideration for placement purposes. *
For example, food/animal/environmental allergies, proximity to a hospital, etc.
In the past I have: *
Please check the box next to the appropriate question(s) if your answer is "yes".
Required
Please explain any boxes marked "yes" in the question above: *
In an instance where an English Opens Doors Program staff member needs to assist you in an emergency, please list any information or relevant family history that an EODP staff member should relay to medical professionals or emergency personnel on your behalf. *
Emergency Contact Information - Contact Person 1
This person would be contacted in the event of a large-scale emergency such as a natural disaster, as well as in the event of a personal emergency in which you are unable to communicate, or need someone to communicate on your behalf.
Full Name *
Relationship to you *
Phone Number *
Please indicate country and area code.
Country of Residence *
Email Address *
Emergency Contact Information - Contact Person 2
This person would be contacted in the event of a large-scale emergency such as a natural disaster, as well as in the event of a personal emergency in which you are unable to communicate, or need someone to communicate on your behalf.
Full Name *
Relationship to you *
Phone Number *
Please indicate country and area code.
Country of Residence *
Email Address *
By typing my name below, I hereby certify, under penalty of exclusion/dismissal from the Program, that the information provided in this document is true and accurate. *
Date *
MM
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DD
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YYYY
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