Health Declaration Form September 2017

PERSONAL INFORMATION

In order to make your participation in University events as enjoyable as possible we need to know of any existing health conditions which may have an impact on you during your time with us. Please give as much detail as possible in this form and if necessary use an additional sheet of paper. If there are any matters concerning your past or present health or future treatment, which are not covered by this form but that you feel are appropriate then please provide additional detail.

The information you give in this form will be treated confidentially within the International Department, we will not share the information with anyone else and the form will be destroyed at the end of your time at Ulster.

While at Ulster University there are staff who are trained in First Aid should you require it. Should you take ill during a University event we will endeavour to have you treated at a local hospital if necessary.

1. Family Name *This question is required.

2. First name *This question is required.

3. Student number (in the format B00 ------ ) *This question is required.

4. Which campus will you study at? *This question is required.

5. Date of Birth *This question is required. This question requires a valid date format of DD/MM/YYYY.

calendar

6. Term Time Address (address you will live at while studying at Ulster) *This question is required.

7. Please give two emergency contact names and numbers
*This question is required.

Name:
Relationship to you:
Telephone No. (including the international country code) :
Name:
Relationship to you:
Telephone No. (including the international country code) :

8. Do your parents/emergency contacts speak English? *This question is required.

9. If No, please tell us which language your parents/emergency contacts use.

10. Have you any special dietary requirements/are you allergic to any foods?

11. If yes, please provide details.

12. Do you suffer from travel sickness? *This question is required.

MEDICAL INFORMATION

13. Are you currently taking, or will you be taking any regular medication which you must continue during your time at Ulster?

14. If yes, please provide details.

15. Do you have any pre-existing medical conditions?

16. If yes, please provide details.

17. Are you allergic to any medication?

18. If yes, please provide details.

19. Are you allergic to sticking plasters?

20. If there are any other conditions you suffer from, whether medical or emotional, which may impact on your enjoyment of or participation in any university event then please give details below.

21. If you have a disability or learning issue that may affect your studies, would you like to receive information about the support available to you?

22. In a emergency, e.g. illness, accident, etc. your emergency contact will be notified immediately. If this proves impossible, do you agree to give Ulster University consent, after taking all available medical opinion, to arrange for all medical and/or surgical treatment to be carried out? Delay in such matters can be life threatening.

Health Declaration Form September 2017

Health Declaration Form - September 2017