Healt form

First Name *

Last Name *

Email *

Place of Birth *

Date of Birth

Nationality

Address

City

Country

Gender

M

F

Other

Program applying

Year

Medical Issue:

Please provide us, Accademia Europea di Firenze (AEF), with your medical information on this form. This will mean that in case of a medical emergency, we will have access to the information on this form. For example, at AEF, students may not have access to US-trained doctors or counselors. Certain medications that are common in the United States may be illegal in Italy, even with a prescription. For these reasons, it is critical that you fully disclose all medical information about yourself whether or not you believe it is relevant.

I have no medical issue (either physical or mental) of which AEF on-site staff should be aware, and I am not on any prescription medication that I will need to take while overseas.

I am disclosing information about a medical issue (either physical or mental) and/or information about prescription medication that I will need to take overseas. (please elaborate below)

Medical Issue

Dietary Needs:

Do you have any special dietary needs?

No

Yes (please elaborate below)

Dietary needs

Additional Information:

AEF staff, in helping you adjust to living and studying abroad, would like to make sure that you remain healthy throughout the duration of the program. Is there any information that you could provide to help them better accomplish these goals? Examples include blood type, religious observance, allergies (food or medicinal), pre-existing medical conditions, learning disabilities or specific learning styles, and anything else that would be helpful for our staff to know. Please note that this information is completely confidential.

Blood Type:

I have read and understood the privacy policy and consent to the processing (as indicated in the privacy policy in point 2 letter b and g)

Yes

No

Health and Medical disclosure form