HEALTH CERTIFICATE EXCHANGE PROGRAM - PART ONE of TWO
Western Australian Association of Teachers of Italian Inc & AFS Intercultura, Colle Val d’Elsa, Siena, Italy
Student given name/s and surnameThis Health Certificate is to be completed by the student and parents or legal guardians. It is to be confirmed
by the student’s examining physician. Please ensure that the Physician signs the form to signify confirmation of
Parts I and II. Every question must be answered in full before a student will be considered for placement.
- Has the student ever had any of the following? Tick the box in the appropriate YES or NO column.
Yes / No / Yes / No / Yes / No
Chicken Pox / Allergies* * / Hernia
Hepatitis / Asthma / Learning or Speech Defect
Measles / Appendicitis / Malaria
Mumps / Cough (persistent, recurring) / Parasites (intestinal, other)
Poliomyelitis / Diabetes Mellitus / Seizure Disorder
Rheumatic Fever / Enuresis / Sleepwalking
Rubella / Goitre / Tuberculosis
Scarlet Fever / Headaches (persistent, recurring) / Vertigo, Dizziness
Any disease, impairment or abnormality of:
Abdominal Organs, Digestive System / Ears or Hearing / Lungs, Respiratory System
Bones, Joints, Locomotor System / Eyes or Vision / Skin (Acne, etc.) **
Blood, Endocrine System / Genito-Urinary System / Tonsils, Nose or Throat
Brain, Nervous System / Heart or Blood Vessels / Varicose Veins
**If YES to Allergies an Allergy Form (page 3 of this form) must be filled out by physician. ** Indicate below any medication, name ,dose, frequency.
2. Give detailed information and dates concerning every disease or impairment ticked YES in any of the above questions. Also list medication details.
Yes / No3.Has student ever been hospitalised? / If yes, give dates, diagnosis and outcome of each accident, illness or operation.
4.Is the student currently taking any injections or medications? / If yes, give name(s) of injections and medication and reasons for use.
5.Has the student ever consulted a neurologist, psychologist, or any other specialist in nervous or emotional disorders? / If yes, attach in sealed envelopes (1) a full report by the specialist, and (2) the candidate’s statement about the illness or specific problem.
6.Are there any health limitations or any medical information which Exchange Administrators should know when considering a placement for the student? / If yes, comment fully
7.Is there any family history of Diabetes Mellitus or neurological disease? / If yes, identify condition and family relationship.
8.Will candidate need any orthodontic care during the coming year? / If yes, please attach a statement from the orthodontist indicating present status, essential care and date care will be complete. Please note the following statement on orthodontic treatment.
Policy regarding orthodontic treatment. WAATI / Intercultura cannot be responsible that a candidate requiring orthodontic care during the program period will receive similar treatment regarding type, quality, and cost. Parents should understand that they are fully responsible for the direct and indirect effects and expenses of any orthodontic treatment.
Policy regarding medical and dental expenses. Intercultura voluntarily pays medical expenses incurred while a student is in the hosting community, except for the cost of dental work, eyeglasses and eye refraction tests, preventive medication, immunisation, or medical expenses related to illnesses or accidents which occurred before the student’s arrival at the departure site. Your signature below signifies that you understand that you are responsible for such costs whilst your son/daughter is on exchange.
PARENT OR LEGAL GUARDIAN’S SIGNATURE DATE ______
Name of parent or legal guardian whose signature appears above
Student applicant name / MEDICAL INFORMATION / FORM 4 Page 2 of 3HEALTH CERTIFICATE EXCHANGE PROGRAM - PART TWO of TWO
Western Australian Association of Teachers of Italian Inc & AFS Intercultura, Colle Val d’Elsa, Siena, Italy
TO BE COMPLETED BY APHYSICIAN DULY LICENSED TO PRACTISE MEDICINE IN STUDENT’S COUNTRY OR STATE.
Examining physician must not be a relative of the student. All questions must be answered in full and certificate must be signed. The consulting physician reserves the right to ask for further information if needed and to make the final decision concerning the medical acceptability of the student. If any existing or previous illness needs to be explained further please attach a separate sheet to this form.
If the student needs to be taking any medication whilst on exchange please supply a covering letter with name of medication, purpose and dose required.
1.Provide figures for vital signs and vision:
a. Height ______Weight ______b.Pulse rate ______
c.Blood Pressure: Systolic ______Diastolic ______
d.Vision: without glasses OD ______OS ______with glasses OD ______OS______
2.If any of the data in Question 1 is in your opinion abnormal, please repeat tests twice, interpret results and comment below.
_
_
Yes / No3.Is there a history, or present evidence of emotional, nervous or mental abnormality (such as nervous fatigue, recurrent nightmares or other similar conditions)? If insufficient space attach papers in a sealed envelope which are signed, dated and clearly identified with name and surname of student. / If yes, please describe in detail giving pertinent dates, medications and results of treatment
4.Does the student have a scar or identifying marks? / If yes, please describe
5. Are there any restrictions on the student’s activities
and/or sports participations? / If yes, please describe
6. Has the student been given a chest X-ray? / If yes, please give dates and results.
- Has the student received any medication during the
a.Reason for which medication or treatment was given
b.Names and dosages of any medication prescribed
c.Date of initial medication, frequency and duration of treatment
d.Date medication stopped
e.The effect if treatment were suspended for a year
f.Date condition was cured, might it recur?
- Describe in detail each disease, impairment or abnormality not fully explained or referred to in Parts I and II of this form.
- How long has this candidate been your patient? ______
10.Give your opinion of the general state of student’s health. (Tick one) / Excellent / Good / Fair / Poor
11.The student has had the following vaccinations and immunizations:NB: Those inRED are compulsory for entrance to Italy on this programme.
Yes / No / DATES / Yes / No / DATES / Yes / No / DATES8CG(TB) / Tetanus / Pertussis
Measles / Poliomyelitis / Rubella
Mumps / Hepatitis B / Smallpox
Influenza(type) / Diphtheria / Cholera
I the undersigned have given a thorough physical examination and reviewed the medical history of the student and certify that all important medical information has been included and that nothing relevant has been omitted. This student is FIT to participate in an 8 to 9 week student exchange program in Italy in the care of a Host Family.
Physician’s name and surname Address – include number, street, suburb and state with postcode
______
Physician’s Degree / s
______
Physician’s Signature
______Date ______
Student applicant name / MEDICAL INFORMATION / FORM 4 Page 3 of 3ADDITIONAL ALLERGY INFORMATION – to be completed by the physician if student suffers any allergies.
If this form is NOT RELEVANT to the applicant please put N/A
We understand that the participant is suffering from some allergies. With this questionnaire we invite you to provide more details about what exactly causes allergic reactions and how it affects the participant. Please be as specific as possible – for example whether the allergies are caused by simply being in the same room with a cat or dog or whether symptoms only appear if the participant touches the animal. Particular explanation required for food allergies.
- Please describe the allergy/ies in detail. Under which circumstances and how often do they occur? What are the symptoms? How long does it affect the general well being of the exchange applicant?
______
- Is any medication taken? If so what kind and how often?
______
- How does the exchange applicant cope with this allergy in everyday life? What are the absolute needs that should be taken into consideration by a hosting family and / or school?
______
- Can this condition be life threatening? What should emergency treatment consist of?
______
______
______
- Any other comment.
______
Physician’s Signature: ______Date: ______
Parent’s Signature: ______Date: ______
Student’s Signature: ______Date: ______
Student applicant name / PARENTAL AUTHORISATION / FORM 5 1 of 2PARENTAL AUTHORISATION
1. PERMISSION TO USE PHOTOGRAPHS AND VIDEO FOOTAGE
Permission to use photographs and video footagePERMISSION TO USE PHOTOGRAPHS AND VIDEO FOOTAGE
We understand that photographs and film and video footage (the images) of current and former candidates are occasionally used by WAATI/Intercultura in promotional materials – eg. The WAATI Teacher Association’s Newsletter. By signing this Agreement, we grant to WAATI/Intercultura the right to use, publish and/or reproduce for any lawful and legitimate purpose excerpts from interviews and letters, images and audio recordings and any other still or moving images of the candidate taken during his/her involvement with WAATI/Intercultura and to use his/her name in this connection. We understand that if we do not wish the candidate’s images to be so used, we must mark the following box and initial the space beside it. By leaving this box blank, we understand that we will be deemed to have consented to such use.
Initial here if you DO NOT give permission for WAATI/Intercultura to use such letters, images and audio recordings of your child.
- AUTHORISATION FOR EMERGENCY MEDICAL TREATMENT
Should any medical emergency arise, if time permits, AFS Intercultura will communicate with us through the WAATI Exchange Coordinator to request permission for surgery or other necessary treatment; however, if in the sole judgment of emergency medical staff, WAATI/ AFS Intercultura, time and circumstances do not permit communication with us, we authorise WAATI/ AFS Intercultura to consent to medical treatment, the administration of x-ray examination, anaesthetics, blood transfusion, medical or surgical diagnosis or treatment and hospital care and to make medical evacuation arrangements and transport, if required, which is deemed advisable by, and is to be rendered under the general or special supervision of any physician and surgeon.
We are aware that some local government or school authorities may require certain vaccinations in order for our child to participate in school or community responsibilities. We understand that we are responsible for any costs related to these requirements.
AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION
- AUTHORISATION FOR RELEASE OF MEDICAL INFORMATION
We hereby authoriseWAATI / AFS Intercultura, and / or a duly authorised medical consultant, to obtain all medical records relating to examinations or treatments for our son / daughter while on the exchange program and any other information concerning such examinations or treatments.
- PERMISSION FOR SCHOOL SPONSORED ACTIVITES (EG CAMPS, EXCURSIONS )
We authorize the AFS Intercultura host parents for my son/daughter during his/her participation in the WAATI/ AFS Intercultura program to execute any authorisation required by our son/daughter’s school for our son/daughter to participate in any school sponsored activities, events or programs.
- SCHOOL COMMITMENT
The student fully understands that this WAATI/ AFS Intercultura program is school-based and family-oriented. The student intends to participate fully in school activities and to complete all assignments and schoolwork as requested while on exchange. We understand that school attendance is compulsory. If the student should neglect the above, the school has the right to deny his/her participation in classes and s/he may be sent home.
- TRAVEL WITH HOST FAMILY
Permission is given to take my/our son/daughter away from the host family home but would appreciate notification of dates and
the whereabouts of my/ our child. It is understood that he/she would NOT travel alone or without a Host Parent.
- AGREED AND ACCEPTED BY
______Date: ______
Signature of Parent /s or Guardian
______Date: ______
Signature of Student
Student applicant name / PARENT STATEMENT / FORM 5 2 of 2Please provide a brief statement about your son / daughter, covering:
1. His / her relationship with you and your family
2. His / her relationships with others
3. His / her reaction to disagreement and discipline
4. What is the amount of parental supervision required by your child?
5. How does your child handle challenging or difficult situations?
6. Reactions to being away from home in the past
PARENT STATEMENT
Student applicant name / SCHOOL REPORT / FORM 6 1 of 1[
Proforma of School Report – delete ALL these instructions highlighted in grey once the information is ready to be printed .
ONLY ONE hard copy is required on original school stationery letterhead. Any other words in brackets and italics are to be deleted also for final copies.
In English - Enter the subjects and courses done by students.. CAF courses may be listed and marks given according to current approximate performance standards of student.
Provide grades as A, B, C, D and E as these are the most readily comprehensible grades in the Italian scholastic environment.
Please complete as per the Semester One report. No comments are required].ADD SCHOOL CREST
2017
SCHOOL REPORT SUMMARY
SEMESTER ONE
Student Name: (Given Name/s and Surname. Delete words within brackets before printing)
School Name:
School Address: (Include street, suburb, post code and full name of state in addressDelete words within brackets before printing)
Academic Record
Subject / ResultsSignature of principal: ______Date : ______
Title, Name, Surname of Principal
Student applicant name: / PASSPORT / FORM 7 1 of 1Insert a colour, scanned copy of your passport. Delete these instructions before printing & submitting.
Student applicant name: / AGREEMENT NOT TO LEAVE HOST FAMILY / FORM 81 of 1AGREEMENT NOT TO LEAVE THE HOST FAMILY
ACCORDO DI NON RICHIESTA DI VIAGGI INDIPENDENTI
I, ______agree not to ask to leave
Con la presente il /la sottoscritto/a, si impegna a non chiedere di lasciare la
my Italian Host Family to visit relatives or friends in other parts of
famiglia ospitante italiana per visitare parenti o amici residenti in altre zone
Italy at any time during my Exchange. Any travel away from the
dell’Italia durante il mio soggiorno. Qualsiasi viaggio dalla città di residenza
Host Family’s residence will be with at least one other adult member of
della famiglia ospitante dovrà essere effettuata con almeno un altro adulto membro
the Italian Host Family.
dalla famiglia ospitante italiana.
EXCHANGE STUDENT SIGNATURE ______
Firma dello studente di scambio
NATURAL PARENT SIGNATURE ______
Firma del genitore
PERSON RESPONSIBLE FOR THIS EXCHANGE
Persona responsabile dello scambio
Ms Fulvia Valvasori – WAATI Exchange Coordinator
DATE ______
Data
Student applicant name: / ACTIVITY WAIVER / FORM 9 1 of 1HOST COUNTRY ACTIVITY WAIVER
We, {FamilyMember} understand and agree that our son/daughter, {ParticipantName}, may have the opportunity to engage in a wide variety of recreational, athletic, or other activities while on AFS organized activities, with host family members, on school activities or with friends and that there are risks associated with these activities. A list of examples of such activities is provided in this two page document. By signing this form, we hereby consent to our son/daughter participating in such activities and confirm that we will not hold the host family or AFS responsible for any harm or injury suffered by our child while participating in these types of activities.
We further understand and accept that if there are certain activities that our son/daughter should not engage in, it is our responsibility to inform WAATI in writing that we do not authorize our son/daughter to engage in that specific type of activity and to advise our child that we have done so and that they are not authorized to engage in such activities while on the AFS Program.
We also confirm that if we are unfamiliar with any of the activities our child might participate in, including but not limited to those listed below, we will take steps to ensure that we understand the scope of those activities and if we are not comfortable with those activities, we will inform WAATI in writing that we withhold authorization for those activities.
We hereby release the host family and AFS Intercultural Programs, Inc. (AFS), its employees, agents and affiliates (such as AFS national and local organizations) and WAATI from and hold each of them harmless against, any and all liabilities, including but not limited to claims for negligence, that they may jointly or severally incur to us or our child, our heirs, executors, administrators, successors and or assigns, in respect of any claim, suit, or cause of action, including legal fees and expenses of litigation, on account of any personal injury, bodily injury, death, loss of health, financial loss or damage to property directly or indirectly sustained by us or our son/daughter as a result of our son/daughter’s participation in the types of activities described in this release or other similar activities. Notwithstanding the foregoing, this release does not apply to intentional wrongdoing or gross negligence on the part of the host family, or AFS, its employees or volunteers. We further understand that the list of activities below does not constitute a promise by AFS or by the host family that our child will have the opportunity to engage in those activities.
Print name / Signature– Parent/Legal guardian / Date
Print name / Signature– Parent/Legal guardian / Date
Print name / Signature – AFS Participant / Date
List of Activities including but not limited to:
Outdoor Activities such as: Backpacking, Biking, Hiking, Horseback Riding, Orienteering,
Team and/or School Sports such as:Basketball, Handball, Rugby, Soccer, Tennis, Volleyball
Water Sports such as:Canoeing, Kayaking, Rafting/Sailing, Scuba Diving/Snorkeling, Surfing, Swimming, Water Skiing
Winter Sports such as: Downhill Skiing, Ice Skating, Sledding, Snowboarding,
Other Activities such as: Free Climbing, Martial Arts