Name:
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Date of birth:
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_______________________________________
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is in good general physical and psychological health, and that an ordinary clinical examination has shown no definite symptoms of illness.
(Please state below any medical conditions that should be taken into account when considering her/his application to become an Au Pair in the United Kingdom/Ireland eg: asthma, allergies, diabetes.) |
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_____________________________________________________
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Date:
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_______________________________________
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Place:
| _______________________________________
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Signature of Physician:
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_____________________________________________ |
Name of Physician:
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_____________________________________________ |
