Medical Clearance Form For Study Abroad printable pdf download

Medical Clearance Form For Study Abroad

Medical Clearance Form for Study Abroad

Please return this form to: Exchange Coordinator, International Center Room 106

Box 3707, Laramie, Wyoming 82071 (307) 766-3677 fax (307)766-3679

Student’s Name:

Student W #:

Phone Number:

Program participating in:

Year________

___Fall Semester

___Spring Semester

___Summer Term

The exchange/study abroad participant is to complete this form with a physician and return it to

the International Programs Office before the end of the semester prior to departure.

DATE:

1) Does the student have any physical or emotional problems which might cause

hardship through change of location and/or travel?

2) Does the student have any dietary, allergic or other medical conditions requiring

special medical attention that might not be available in a foreign setting?

(orthodontics, contact lenses….)

3) To your knowledge, does the student have any predisposing medical, surgical or

emotional factors which may, under stress or duress during a program, present a

need to immediate therapy while away?

4) Please list any serious illnesses the student has had in the last three years.

I have reviewed the above information and the student health record of the above named

individual. To the best of my knowledge, there are no medical, psychological, or emotional

problems to preclude participation in a student exchange/study abroad program.

Signature of Physician

Printed Name

Address

Phone Number

Student Signature

Date

Medical Clearance Form For Study Abroad