Student Exchange Health Declaration Form
Full Name
Date of Birth
Gender
Male
Female
Other
Prefer not to say
Passport Number
Nationality
Contact Number
Email Address
Current Address
Emergency Contact Name
Emergency Contact Phone
Relationship
Do you have any chronic illnesses or allergies?
Are you currently taking any medication? Please specify.
Have you had any recent surgeries or hospitalizations? If yes, please explain.
COVID-19 Vaccination Status
Fully vaccinated
Partially vaccinated
Not vaccinated
Other relevant medical information
Date
Signature