Zdravotní informace před cestou pro au-pair

                                         MEDICAL INFORMATION

NAME…………………………………………………………………………
DOB…………………………………
ADDRESS:……………………………………………………………………..

…………………………………………………………………………………..

…………………………………………………………………………………..

IMMUNIZATION RECORD

Tetanus			Measles			Small pox

Whooping cough		Mumps			German Measles

Polio				Others

ALLERGIES

penicillin		asthma			hay fever		insect (s)

hives			pets			other/drugs

EMERGENCY CONTACT

NAME…………………………………………………Relationship……………………

DAY PHONE NUMBER………………………

EVENING PHONE NUMBER…………...

DECLARATION

I hereby certify that information above is correct and Ms………………………………………

is able to stay in Great Britain as an au-pair.

Stamp and signature of your doctor				Signature of applicant