Homestay Medical Information Disclosure Form
Student Information
Full Name
Date of Birth
Gender
Male
Female
Other
Contact Number
Emergency Contact
Name
Relationship
Phone Number
Medical Information
Describe any existing medical conditions
List any allergies
Current medications (include dosage)
Dietary restrictions or special needs
Insurance Information
Insurance Provider
Policy Number
Consent
I hereby authorize the disclosure of my medical information to my homestay family and relevant authorities as required.