EJO English Language Courses - Enrolment Forms

English Home Lessons & Intensive English Courses Medical Information Form

Thank you for enrolling in an EJO English Home Lesson. Please now fill out the Necessary Medical Information Form.

We will contact you shortly to confirm your registration. In the meantime, please complete and submit the form below. It is ESSENTIAL for us to have this information in case of emergency. Any queries please contact us on +44 1428 751549 or email at info@ejo.co.uk

* means this is a required field

* means that item must be filled in

Students Details:

Emergency Contact Details (Next of Kin):

Medical Insurance:

Is the student covered by medical insurance?

Does he/she have any of the following?

Medical Conditions:

Does the student suffer from any of the following? If YES, please give details below:

Asthma/bronchitis

Fits, fainting, blackouts

Allergies to medication

Other allergies e.g food, animals

Heart condition

Diabetes

Migraine/severe headaches

Travel sickness

Other illness/disability

Regular medication

If it is considered necessary, do you consent to mild pain killers (e.g Paracetamol) being administered?

Has the student been vaccinated against tetanus in the last 10 years?

Has the student had surgery/specific medical treatment of any kind recently? (If the answer is YES, please give details below)

Declaration:

Intensive English Courses for adults where the focus is on improving your language skills as quickly and efficiently as possible.