AU PAIR USA 2010 Application to Become Au Pair Part 2

AU PAIR USA

Medical Report
PART I: To be completed by Applicant
International Cooperator: Applicants Last Name: Address: State/Province: Country: Date of Birth:
MM/DD/YYYY

First Name: City: Postal Code: Telephone: Gender: Male Female

011COUNTRY CODECITY CODEPHONE NUMBER

Height (cm):

Weight (kg):

PRIMARY EMERGENCY CONTACT Name: Address: State/Province: Telephone: Postal Code: Email: Relationship to Applicant: City: Country:

011COUNTRY CODECITY CODEPHONE NUMBER

ALTERNATIVE EMERGENCY CONTACT (In case of emergency, if primary contact is unable to be contacted) Name: Address: State/Province: Postal Code: Telephone: City: Country: Yes No

011COUNTRY CODECITY CODEPHONE NUMBER

Are you covered by additional insurance beyond that provided by the InterExchange program? If yes, please give details:

Note: Insurance provided by InterExchange will not cover the cost associated with any pre-existing condition.

Check the appropriate box if you are presently suffering from or have ever had:
Anemia Anorexia Arthritis Asthma Bulimia Chicken pox Depression Diabetes Dizziness/fainting Epilepsy/convulsions German measles (Rubella) Glandular fever Hepatitis Hernia Herpes Malaria Measles Meningitis Mental or nervous disorder Migraine/headaches Mumps Rheumatic fever Scarlet fever Tuberculosis Typhoid fever Ulcers Other Any disease/impairment/abnormality of: Blood or endocrine system Bones, joints, musculoskeletal system Brain or nervous system Ears Eyes Gastrointestinal system Genitourinary system Heart Lungs, respiratory system Nervous system Skin Tonsils, nose or throat

If you answered yes to any of the above, please give details including dates if applicable:

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AU PAIR USA 2010 Application to Become Au Pair Part 2

Do you suffer from any allergies? Penicillin Other drugs Insect sting Hay fever Foods Other

If you checked any of the above, please give details including dates if applicable:

General Health: Is your physical activity restricted in any way? Have you ever received treatment for a nervous or emotional problem? Have you ever been treated by a psychiatrist? Are you currently taking any medications? Do you have any habits that may affect your health (i.e. alcohol, cigarettes, drugs)? Do you have any chronic or recurring illness? Do you currently have any infectious diseases? Do you have any dietary restrictions? Are you pregnant? Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No No

If you answered yes to any of the above, please give full details including the names of any medications:

Have you been hospitalized?

Yes

No

Have you ever undergone surgery?

Yes

No

If you answered yes to any of the above, please give full details with dates:

I hereby certify that all information given is correct, and that withholding or falsifying any information may result in me being withdrawn from the program. I also accept full responsibility for any medical expenses which are not covered by my insurance policy.

SIGNATURE

DATE (MM/DD/YYYY)

Important: Compensation under medical expense policies for Travel Insurance Services does not include the cost of normal dental/vision treatment not due to an accident. It is therefore important for any person traveling abroad to receive thorough dental/eye examinations prior to departure so that no unexpected complications arise during the period of residence abroad. Dental/vision treatment can be very expensive in the USA.

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AU PAIR USA 2010 Application to Become Au Pair Part 2

PART II: To be completed by a Medical Doctor not related to candidate in any way

As an au pair in the United States, the applicant will live and be responsible for young children. It is therefore important that we are advised of any physical or mental health problems that may have any effect on the applicants ability to participate.
A. Please review the information provided by the applicant in Part I of this form. B. Please indicate whether the applicant has been immunized against the following: Tetanus Diphtheria Polio Measles German measles (Rubella) Yes Yes Yes Yes Yes No No No No No Date: Date: Date: Date: Date: Typhoid Tuberculin test Mumps Whooping cough Yes Yes Yes Yes No No No No Date: Date: Date: Date:

C. Are there any abnormalities of the following organs and/or systems: Head, ears, nose, throat Respiratory Cardiovascular Gastrointestinal Eyes Genitourinary Yes Yes Yes Yes Yes Yes No No No No No No Musculoskeletal Metabolic Nervous Skin Other Yes Yes Yes Yes Yes No No No No No

If the answer to any of the above is yes, please explain in detail (attach additional page if necessary):

D. Is the applicant currently or has the applicant recently been treated/counseled for a nervous condition, depression or emotional disorder? If yes, please explain in detail (attach additional page if necessary):

Yes

No

E. Do you have any reservation, comments or concerns about this applicants ability to provide up to 45 hours of weekly childcare in an American host family? If yes, please explain in detail (attach additional page if necessary):

Yes

No

NAME OF DOCTOR

TELEPHONE

ADDRESS

SIGNATURE

DATE (MM/DD/YYYY)

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