健康声明书

健 康 声 明 书
请尽可能准确地回答下列有关健康方面的问题。

倘若在填写过程中有任何疑问，请及时向EF 的咨询顾问寻求协助。

您的子女是否有以下方面的疾病、损伤或不良反应？请在合适的栏目内打勾：
有 否 视觉或听觉
扁桃体、嗅觉或咽喉
胃或消化系统
您的子女是否曾患有以下疾病？如有，请详细说明：
有 否
有 否
哮喘
甲肝 阑尾炎 乙肝
水痘 丙肝
癫痫 麻疹 食欲不振 腮腺炎
过敏症
请列明过敏症的种类并说明患病程度：
___________________________________________________________________________
倘若您的子女患有上述或其他疾病，请详细说明：
___________________________________________________________________________
您的子女目前是否在接受治疗,包括过敏症? 是 否 如果是，请注明病症和原因？ ________________________________________________________________________
您的子女是否曾接受过心理治疗? 是 否 如果是，请注明：
________________________________________________________________________
此声明一经签名，即证明本申请表上的所有内容均属实，同时也表示EF 游学项目负责人在必要的时候，在医生或保健专家建议下，为学生安排医疗保健服务，包括住院治疗等一切行为都已得到了您授权。

其次，在学生保险范围以外所发生的医疗费用也将由您一并负责承担。

另外，在必要情况下，您将会积极配合提供医生书面的英文声明，以证明您的子/女有良好的健康状况且也适合参加此项目。

_______________________________ ____________ 家长或监护人签名（18岁以下学生） 日 期
_______________________________ ____________ 学生签名 日 期
Language Travel 英孚海外游学
Medical Release and Consent Form /CA.v1
MEDICAL RELEASE AND CONSENT FORM
MEDICAL RELEASE AND CONSENT FORM
Please answer the following health questions as accurately as possible. If you have difficulty completing this form in English, please
contact your local EF office for assistance.
Has applicant ever had a disease, impairment or abnormality of the following:
Yes
Yes No No No
Eyes or Ears
Tonsils, Nose or Throat
Stomach or Digestive System
Has applicant ever suffered from any of the following? Indicate by checking the appropriate box.
Yes Yes No No
Yes Yes Yes No No No
Asthma
Appendicitis
Chicken Pox
Epilepsy
Eating Disorder
(Anorexia Nervosa, Bulimia, etc)
Hepatitis A
Hepatitis B
Hepatitis C
Measles
Mumps
Allergies
Please list types of allergies and describe the severity:
If yes to any of the above, or if your son/daughter has any other medical condition, please give a detailed description:
Is applicant currently taking any kind of medication, including those for allergies?
Yes Yes
No
No If yes, what and why?
Has applicant ever been under the care of a doctor for any kind of psychological disorder? Yes Yes Yes
No No No
If yes, please describe.
Your signature verifies that the information on this page is correct to the best of your knowledge and that you authorize EF Education Education, and its personnel, to arrange for necessary medical treat , and its personnel, to arrange for necessary medical treat , and its personnel, to arrange for necessary medical treatment for your son/daughter, including hospitaliza ment for your son/daughter, including hospitaliza ment for your son/daughter, including hospitalization tion and any emergency operation, which is determined necessary by a doctor or health care professional and any emergency operation, which is determined necessary by a doctor or health care professional during his/her stay during his/her stay abroad. You abroad. You also accept full responsibility for any medical expenses which are not covered by his/her insurance policy also accept full responsibility for any medical expenses which are not covered by his/her insurance policy also accept full responsibility for any medical expenses which are not covered by his/her insurance policy. . . A A doctor’s doctor’s clearance/medical certificate (in English or original version accomp clearance/medical certificate (in English or original version accomp clearance/medical certificate (in English or original version accompanied by English translation) may be anied by English translation) may be anied by English translation) may be necessary necessary to attest that the student is in good health and able to participate in th to attest that the student is in good health and able to participate in the program.e program.e program.
Parent’s or guardian’s signature (if student is under 18 years of age)
Date
Student’s Signature
Date
Student’s Printed Name
Date
T O B E C O M P L E T E D I N E N G L I S H。