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:
___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.
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
Phone Number
Student Signature


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