MEDICAL CERTIFICATE

This is to certify that:

Name: _________________________________________________________________________
Date of birth: ____________________________________________________________________
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/ Spain e.g.: asthma, allergies,
Diabetes.
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Please review the information provided by the applicant and give us your opinion of the applicants general
state of health:
Excellent: ( )

Good: ( )

Ok: ( )

Poor: ( )

Date: _____________________ Place: ___________________________

Signature or stamp of
Physician __________________________________________________________
Name of
Physician __________________________________________________________