Signature of Home Institution Official Date Health & Safety Information Questionnaire This form is to be completed by the applicant (Student). Last Name: First Name(s): The purpose of this form is to help UCC to be of maximum assistance to you should the need during your study abroad experience. Mild physical or psychological disorders can become serious under the stresses of life while studying abroad. It is important that UCC be made aware of any medical or emotional issues, past or current, which might affect you in a foreign study context. Please note that UCC may not be able to accommodate all individual needs or circumstances. Medical History 1 Are you generally in good physical condition? Yes No If No, please explain: 2 Have you ever been treated or are you currently treated for any Yes No psychological or emotional issues? If Yes, please explain and indicate any medication which has been prescribed: 3 Do you have any allergies to drugs, insects, plants or food? Yes No If Yes, please explain: 4 Do you any indication of your allergies which would assist UCC or Yes No medical staff in the event of illness?
Signature of Home Institution Official Date Health & Safety Information Questionnaire This form is to be completed by the applicant (Student). Last Name: First Name(s): The purpose of this form is to help UCC to be of maximum assistance to you should the need during your study abroad experience. Mild physical or psychological disorders can become serious under the stresses of life while studying abroad. It is important that UCC be made aware of any medical or emotional issues, past or current, which might affect you in a foreign study context. Please note that UCC may not be able to accommodate all individual needs or circumstances. Medical History 1 Are you generally in good physical condition? Yes No If No, please explain: 2 Have you ever been treated or are you currently treated for any psychological or emotional issues? Yes No If Yes, please explain and indicate any medication which has been prescribed: 3 Do you have any allergies to drugs, insects, plants or food? Yes No If Yes, please explain: 4 Do you any indication of your allergies which would assist UCC or medical staff in the event of illness? Yes No
VisitingStudentApplicationForm2017-2018.docx