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Last name

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Gender:

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Male

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Date of Birth

Student ID

Student Email

Phone Number

Student Photo

: : : : : : : : : : : : :

Asthma, wheezing, Respiratory? Yes No
Bronchitis and/or shortness of breath? Yes No
Physical disability or other disability? Yes No
Are you pregnant? Yes No
Do you smoke? Yes No
Epilepsy, seizures, fainting attacks or convulsions? Yes No
Any other neurological problem? Yes No
Recurring migraine headaches, Blackouts? Yes No
Recurring joint, mobility or back problems/surgery? Yes No
Diabetes? Yes No
Any hearing loss or problems with balance? Yes No
Any serious eyesight issues? Yes No
Drug or alcohol dependency? Yes No

Please Provide any Medical Condiotions if any

Doctor's Full Name :

Doctor's Phone Number

: :

: Next of Kim First Name

: Next of Kim Last Name

Next of Kim Phone Number

: :

Next of Kim Relationship :

South East Technological University is one of the largest technology colleges in Ireland, with campuses in Carlow, Wexford and Wicklow, and part-time provision elsewhere in Ireland. It will become a founding constituent institute of Technological University for the South East in May 2022.

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