Student Exchange Tourist Medical Information Declaration Form
Personal Information
Full Name
Date of Birth
Passport Number
Nationality
Email Address
Contact Number
Program Information
Hosting Institution
Duration of Stay
Arrival Date
Emergency Contact
Emergency Contact Name
Relationship
Contact Number
Email Address
Medical Information
Blood Type
Do you have any allergies?
Are you currently taking any medication?
Do you have any chronic medical conditions?
Additional Medical Information
Declaration
I declare that the information provided is true and complete.
Signature
Date