Student Health Form for over 18 Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Student Name *FirstLastDate of Birth *Email *MEDICAL HISTORYPlease tick any of the following medical conditions if your child is currently suffering from: *AsthmaADHD or ADDMigrainesFits of any typeBack / Neck problemsDepression / AnxietyHepatitis A, B or CDizzy SpellsGlandular FeverAutism / Asperger'sEpilepsyHeart ConditionEating DisordersTuberculosisChronic Nose BleedsDiabetesColour BlindnessHIV or AIDSBedwettingSleep WalkingTravel sicknessOtherNonePlease state medical condition/s: *Is student currently taking any medication? *Yes / NoNoYesIf yes, please state Health condition/s: *Name of medication/s: *Dosage and time/s to be taken: *Other treatment: *Has student suffered a serious illness or injury in last 5 years? *Yes / NoNoYesIf yes, please provide details *Has student had any surgery in last 5 years? *Yes / NoNoYesIf yes, please provide details *ALLEGIESIs student allergic to any medication? *Yes / NoNoYesIf yes, please provide details *What treatment is required? *Does student have any food allergies? *Yes / NoNoYesIf yes, please provide details *What treatment is required? *Does student have any allergies to insect bites/stings? *Yes / NoNoYesIf yes, please provide details *What treatment is required? *Does student have any other allergies? *Yes / NoNoYesIf yes, please provide details *What treatment is required? *OTHER HEALTH INFORMATIONDoes student have a congenital condition? *Yes / NoNoYesIf yes, please provide details *Any other disabilities or conditions not mentioned above? *Yes / NoNoYesIf yes, please provide details *Homestay Student Health Declaration *I understand and agree with the discussion points belowI declare that I will disclose to Happy Homestay Adelaide (HHA) any medical condition that I might contract prior to or during student’s stay at the homestay. Additionally, I agree to disclose any pre-existing medical or health condition of student that may require ongoing or intermittent medical attention or that may affect the homestay family. I agree that if prescribed medication needs to be administered, a designated adult of host family will be assigned to do this. I will ensure that prescribed medication is clearly labelled, securely fastened and handed to the designated adult with instructions on its administration. I will inform the HHA as soon as possible of any changes to medical or other circumstances detailed here. I agree to student receiving any emergency medical, dental, or surgical treatment, including anaesthetic or blood transfusion, as considered necessary by the medical authorities present. I confirm that homestay host and HHA are not responsible for any issues caused by inaccurate health-related conditions, and the student will be required to move out immediately if such conditions are revealed. In this event, the homestay fee is non-refundable, and arranging alternative accommodation will not be the responsibility of HHA. I agree and acknowledge that HHA may collect personal information including medical information as a result of homestay application and health form, being informed from the institution and/or staying at the homestay and acknowledge that this information will only be used for the arrangement of homestay, and medical service either directly or indirectly and no other purpose.Student Name *FirstLastSignature of Student * Clear Signature Date *Submit