AU-PAIR WORLD AGENCY SWEDEN
Museigatan 2
SE-451 50 Uddevalla
SWEDEN
AU-PAIR
MEDICAL CERTIFICATE
First name: ____________________ Last name: ___________________________________
Address: _____________________________________________________________________
Telephone number:___________________________________________________________
Date of birth:_________________________________________________________________
To be filled out by the physician: Are there any medical reasons against the patient going abroad as an Au Pair? Yes ___ No___ If yes, please explain: ______________________________________________________________________ Does the patient suffer from any allergies? If yes, which ones: __________________________________________________________________________________________ Comments: (Please include any details that you feel are important to know before the applicant is placed as an Au Pair in a host family abroad): __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ I hereby certify, to the best of my knowledge, that the above applicant is completely healthy, both physically and mentally. Physician s name: _________________________________________________________________________ Signature of Physician: ____________________________________________________________________ Date of examination: ______________________________________________________________________ Physicians stamp: .