MEDICAL REPORT

Medical Report

TO BE COMPLETED BY YOUR DOCTOR

Doctor's name (BLOCK CAPITALS)
Doctor's name (BLOCK CAPITALS)
First
Middle
Last

TO THE PHYSICIAN:

Applicant's Name
Applicant's Name
First
Middle
Last

has applied for a school/staff/volunteer position with Youth With A Mission - Uganda. We need to have a medical report on the applicant to assess their suitability for working and living in a developing country in Africa where medical services are limited. The position will expose them to cross-cultural and community living that may well be stressful.

Thank you for making this Medical Report for us.

PLEASE PRINT(Please use a separate sheet of paper where the space provided is inadequate):

Please answer the following questions regarding the applicant’s health:

WEIGHT

HEIGHT
Is the applicant under medical supervision at this time or taking any medication?

Please return this medical report by post immediately to:

YWAM Hopeland

P0 Box 739

Jinja

UGANDA

www.ywamhopeland.org      E-mail: hopeland@ywamuganda.org