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Get Au Pair Medical Certificate

Ever been convicted of a criminal offence, or are you at present the subject of criminal charges? Yes No If yes, give full details I understand and agree that American host families may have access to this Medical Form and give permission to the Doctor completing Part B to review all my responses in Part A of this form and to provide or discuss additional medical information, if requested to do so by Au Pair in America. Should an emergency situation arise, I authorize any medical provider to.

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