LC Exchange Guide+School Toolkit - Flipbook - Page 30
Sample medical form
[School name]
Medical consent form
[Language] Exchange
Dates of trip:
Leader:
Name of Student:
Date of Birth:
Home Address:
Home Telephone Number:
Mobile Telephone Numbers:
1 – Name + number:
2 – Name + number:
Name of Emergency Contact 1
and relationship to student
Name of Emergency Contact 2
and relationship to student
Mobile phone number and email address
Mobile phone number and email address
Name of Family Doctor, Address and Telephone Number:
Dietary Requirements:
Medical Conditions & Medication Used
(Please specify if the child can administer the medication themselves or if a
member of staff/host family will be responsible for this).
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How-to Manual for School Exchanges
How-to Manual for School Exchanges
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