University Study Abroad Health Clearance

University Study Abroad Health Clearance — Form Fields

This education template includes 16 fields. Health clearance form required for students participating in study abroad programs. Free to customize and use on ZenBuild.

• Student Name (text, required)
• University Email (email, required)
• Student ID (text, required)
• Study Abroad Program and Country (text, required)
• Program Dates (text, required)
• Physician Name (text, required)
• Physician Phone (text, optional)
• Health Insurance Provider (text, required)
• Policy Number (text, required)
• Vaccinations Up to Date (multiple choice, required) — options: Yes, No, In Progress
• Required Vaccinations Completed (checkboxes, required) — options: Hepatitis A, Hepatitis B, Typhoid, Yellow Fever, Meningitis, MMR, Tdap, COVID-19
• Current Medications (text, optional)
• Known Allergies (text, optional)
• Chronic Conditions or Disabilities (long text, optional)
• Mental Health Concerns (multiple choice, optional) — options: Yes - Currently in Treatment, Yes - Managed, No
• Physician Clearance Letter (file upload, required)