International Student Exchange Tour Health Declaration Form
Personal Information
Full Name
Date of Birth
Nationality
Passport Number
Email Address
Contact Number
Emergency Contact
Contact Name
Relationship
Contact Number
Medical Information
Do you have any pre-existing medical conditions?
If yes, please specify
Are you currently taking prescription medication?
If yes, please specify
Do you have any allergies?
If yes, please specify
Recent Vaccinations (specify date and type)
Travel and Exposure Information
Have you traveled internationally in the last 30 days?
If yes, list countries visited
Have you been in close contact with someone diagnosed with a communicable disease in the past month?
If yes, please provide details
Declaration
I confirm that the information provided is accurate and complete to the best of my knowledge.
Signature
Date