AFS Application Form

Health Certificate (Page 1 of 2)

To be completed and signed by the candidate’s physician. The physician should not be related to the candidate. For questions 3-14: if the answer is "YES", a
detailed explanation must be given here or attached in a separate report. AFS reserves the right to ask for further information and determine if the candidate
meets the program medical qualifications. The candidate and parent/guardian must also sign.

CANDIDATE NAME HOME COUNTRY

BIRTH DATE HEIGHT WEIGHT

DD MMM YYYY

1 B/P PULSE RESPIRATION BLOOD TYPE

2 Do you note any abnormalities concerning height, weight (including substantial loss or gain in the past six months), blood pressure, pulse or respiration?

No Yes (describe)

3 Please check the appropriate box. Has the candidate HAD any of the diseases/conditions listed below:

MEASLES No Yes IF KNOWN Titer: Date: / / RHEUMATIC FEVER No Yes

MUMPS No Yes IF KNOWN Titer: Date: / / COUGH (PERSISTENT, RECURRING) No Yes

RUBELLA No Yes IF KNOWN Titer: Date: / / HEADACHES (PERSISTENT, RECURRING) No Yes

CHICKEN POX No Yes IF YES Month: Year: SLEEPWALKING No Yes

POLIOMYELITIS No Yes ENURESIS No Yes

HEPATITIS No Yes APPENDICITIS No Yes

TUBERCULOSIS No Yes PARASITES (INTERNAL) No Yes

If yes, give detailed information and dates (use extra pages if necessary):

4 ACNE No Yes If yes, identify area, severity, any medication taken, name, dosage & frequency:

5 ALLERGIES No Yes If yes, identify type, any medication taken, name dosage & frequency:

6 ASTHMA No Yes If yes, identify type, severity, any medication taken, name, dosage & frequency:

7 DIABETES No Yes If yes, identify type, severity, any medication taken, name, dosage & frequency:

SEIZURE
8 No Yes If yes, identify type, severity, any medication taken, name, dosage & frequency:
DISORDER

9 Has the candidate ever had any disease, impairment or abnormality of:

Abdominal organs, digestive system No Yes Heart blood vessels No Yes

Lungs, respiratory system No Yes Tonsils, nose or throat No Yes

Bones, joints, locomotor system No Yes Blood, endocrine system No Yes

Genito-urinary system No Yes Eyes/vision, ear/hearing No Yes

If yes, please explain (use extra pages, if necessary )

10 Has the candidate been hospitalized? No Yes

If yes, give dates, diagnosis and outcome for each incident.

 AFS Application Form

Health Certificate (Page 2 of 2)

CANDIDATE NAME HOME COUNTRY

11 Is the candidate currently taking medication or injections (other than those mentioned previously)? No Yes

If yes, identify the medication, reason for usage, dosage and frequency:

12 Has the candidate EVER consulted a neurologist, psychologist or any other specialist for a nervous, emotional or eating disorder? No Yes

13 Is there a history of, or present evidence of, an emotional, nervous or eating disorder? No Yes

If yes to either (12 or 13), a FULL report by the specialist and a statement by the candidate about the illness or specific problem must be attached in a sealed envelope.
Note: Placement in a foreign host family, school and community requires adjustment which often involves emotional stress. It will not be a time for relaxation or
temporary relief from any current therapy. If the candidate is experiencing current emotional, physical, personal or family difficulties, these difficulties can be severely
exacerbated by the adjustment demands of the AFS program. Therefore, you are requested to evaluate carefully the candidate’s current or previous condition and
treatment along with his or her ability to manage potential adjustment anxieties and stress in a foreign environment.

14 Are there any health limitations or restrictions on the candidate’s activities and/or sports participation, or any medical information
No Yes
which should be considered for a home/school placement?

If yes, please describe:

15 Does the candidate wear glasses or contact lenses? No Yes

DATE
16 What was the date of the candidate’s last dental check up?

Does the candidate wear dental braces? No Yes

FREQUENCY
If yes, will orthodontic care be needed while on the program? No Yes

17 Please specify exact day, month and year that the candidate had the following immunizations:

MEASLES Dates: TETANUS Dates:

MUMPS Dates: POLIOMYELITIS Dates:

RUBELLA Dates: BCG Dates:

DIPHTHERIA Dates: HEPATITIS B Dates:

PERTUSSIS Dates: OTHER Dates:

TB Test—which type (circle one): Mantoux or Tine Date: Result + -

If positive, was chest x-ray done? No Yes Date: Result + -

I, the undersigned, certify that a thorough physical examination of the candidate has been given and all important recent medical information has been included on
the health certificate, that nothing relevant has been omitted, and that the candidate is able to travel. I understand that the omission of any information could be
harmful to the candidate’s health care and could result in early termination from the AFS program.

PHYSICIAN NAME AND DEGREE SIGNATURE

ADDRESS DATE

Your signature below attests that you understand and accept the AFS Medical Policies as stated on the Participation Agreement, that the information on the health
certificate is correct and complete and that inaccurate or incomplete information could be harmful to the candidate’s health care and could result in early termination
from the AFS program.

CANDIDATE SIGNATURE DATE

PARENT/GUARDIAN SIGNATURE DATE