Please acknowledge you have read the above notice and agree with it before filling in this form on behalf of your child: Please acknowledge you have read the above notice and agree with it before filling in this form on behalf of your child: I Agree

First Name

Family Name

First Name for Name Tag

Date of Birth (dd/mm/yy)

Sex SexMaleFemale

Place of birth

Nationality

Does your child need a visa for France? Does your child need a visa for France? Yes No

Country you have been living in

Country where your child has been attending school (if different)

Total years/months on the field

Length of stay on field this term

Reasons for coming home this time (if different from parents)

Special concerns connected with changing locations at this time or anything different we should understand concerning a crisis this child has been through

Preferred language for debriefing - 1st choice Preferred language for debriefing - 1st choiceEnglishFrenchDutchGermanSwiss German

Preferred language for debriefing - 2nd choice Preferred language for debriefing - 2nd choiceSame as first choiceEnglishFrenchDutchGermanSwiss German

Is your child taken any prescribed medications? Is your child taken any prescribed medications? yes no

Please explain

Is your child under the care of a professional psychologist or psychiatrist? Is your child under the care of a professional psychologist or psychiatrist? yes no

Please explain

If your child is on a special diet or has any special food requirements, please explain