Download Statement of Fitness

Survey
yes no Was this document useful for you?
   Thank you for your participation!

* Your assessment is very important for improving the work of artificial intelligence, which forms the content of this project

Transcript
Fax this form from the physician’s office to the Study Abroad Office at (860)465-5363.
This form will not be accepted from a student unless in a sealed envelope with the
physician’s signature over the seal. No exceptions will be made.
Statement of Fitness Declaration
I, Dr.__________________________________________, declare that Mr./Mrs./Ms.
_________________________ is medically, mentally and physically fit and able to travel to
____________________ and participate in Eastern Connecticut State University’s Global Field
Course. I have read and reviewed the Center for Disease Control’s health and safety information
related to the Global Field Course destination and find no information that would prevent my
patient’s participation. I have enclosed any pertinent information concerning my patient’s health
condition and/or treatment that could aid the Global Field Course Director in safeguarding the
health of my patient should a medical situation or necessary treatment arise. To the best of my
knowledge, the prescribed medication listed below is both legal and readily available in the host
country.
Medications
Condition
Signature: ______________________________________________
Date: _____________
Rev. 10/10