=o cornta 4) UNIVERSITY G D GOENKA UNIVERSITY HEALTH CLEARANCE FORM Health clearance forms are used by GDGU to establish and maintain conditions for a safe and healthy environment. Your cooperation in completing the form will help ensure that the student residences remain safe andhealthy for all. GDGU will notbe responsible for any medical problem that arises during the students stay at the Hostel Al students staying in the residences are required to complete the Health Clearance Form. Incomplete forms will not be accepted. Failure to complete this form in all respects will absolve the university of any legal liabilities, as well as the university can ask the student to leave the hostel. Any accident that may occur will absolve the GDGU of any legal liabilities. Any health problems occurring due to consumption of Liquor/Drugs/Tobacco products et. the University will not be liable for any mishap and any compensation. The students will need to take a "Medical Insurance" for the complete period of stay at the University {Attach the Medical Insurance Record with this form). ‘Any hospitalization of any foreign students will have tobe paid forby the students o the concerned hospital directly by them. 1, Name (First Name/Sumame) 2, Date of Birth 3. Emergency Contact Person's Name| a ‘& mobile no 4, What health problems or conditions (Disease, illness or injuries) have you had in the past two years? Problem/Condition| Dates: Treatment & by whom | Are you sil under treatment? 5. Have any of these health problems or conditions been of a serious nature or resulted in your hospitalization? Give Details 6.Please list all health/medical problems, conditions or special needs you have which you think might affect your health or medical condition while residing at the Student Residences at GDGU. Failure to inform GDGU will result inno liability to the Institution.7.Chest X-Ray Donotsend X-Ray film, send only the statement of results by recording them in the space provided below. Date ‘Negative/Normal Questionable ‘Abnormal a _—mm—y Ifinterpretedas “questionable” or “abnormal”, explain below: NOTE: The health professional must record his/her name, title, signature and address on the space provided below: Health Professional's Name & Tite/Qualifications: ‘Address ] Health Professional's Signature/Stamp: cochch 8. | declare that the information on this form is true and complete to the best of my knowledge and attest that | am in good health and condition to reside in the Student Residences of GDGU. | also absolve the Institute of any mishap that may occur during my stay at the hostel. Signature of student / Parent Date * subcohort ieton