Download Statement of Fitness

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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
Signature: ______________________________________________
Date: _____________
Rev. 10/10