REFERENCEFORMC-StaffHealth

Dear Physician,

We request your help in providing us with information about applicant’s physical health.

The applicant is applying to be on staff that requires the person to have a good health and a reasonable level of physical fitness. He / She may be required to participate in overseas field trips and outreaches.

Your examination & assessment of this applicant will be crucial for YWAM Singapore’s consideration of acceptance.

Thank you.

Warm Regards,

Registrar,

YWAM Singapore
Geylang P.O. Box 25
Singapore 913801
Tel:+65-67459700 Fax:+65-67477533

General Enquires: info@ywam.org.sg

Staff Reference - HEALTH

Part A - Applicant's Examination
For the Physician/Doctor's assessment
Name of Applicant*
Name as in passport
First Last
Applicant's NRIC*

Identity Number/Passport Number
Height:*
Weight:*
Blood Type:*
Blood Pressure:*
Pulse Rate:*
Regularity:
HISTORY*
Any history - personal, medical / operation, mental, family
General Examinations*
EYES
Left Right
Eyesight*
- With corrective glasses
- Without corrective glasses
General Examinations*
EARS
Left Right
Chest (lung & heart):*
Abdomen (liver / spleen enlargement):*
Genital-urinary system:*
Any other condition that YWAM Singapore should take note of?*
Recommendation on fitness to study and/or overseas travel*
- Acceptance without any limitation
- Acceptance with limitation (please specify below)
- Not acceptable
- Should remain in areas where adequate medical care is available
Specify limitations*
Date of Examination*
How long have you known the applicant?*
Years Months
Part B - Physician's Details
Physician’s name:*
First Last
Name of Clinic*
Phone*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Save and Continue Later

Left	Right

Left	Right

Years	Months

HEALTH DECLARATION : To be completed by Physician

Staff Reference - HEALTH

Part A - Applicant's Examination

Part B - Physician's Details