Mrs. J. Beth Ciesielski, Executive Director & Founder	94 Lamarck Drive  Buffalo, NY 14226
Bridges for Education, Inc.	TEL 716-839-0180  FAX 716-839-9493
E-Mail: jbc@bridges4edu.org
Webpage-http://www.bridges4edu.org
BRIDGES FOR EDUCATION   2010
PHYSICIAN'S CERTIFICATE

*** Mail completed form to your Group Leader- NOT to BFE! ***
Group Leader_______________________Country__________
Address____________________________________________
This form must be completed by a physician familiar with your health and medical history on the basis of a physical examination.
Teacher  name_____________________________________________________________
                         last                                          first                                 middle
Address_________________________________________________TEL.(___)_________

This program sends volunteers to teach conversational English in Eastern Europe and Asia for the summer. The experience is like a mini Peace Corps assignment: bathroom and sleeping facilities are often BASIC. There are few elevators and teachers are expected to carry their own bags. There is no air conditioning. Applicants must be in excellent health, and fit to handle strenuous activities. They must not be restricted in the foods they can eat, nor require special diet or treatment, which will unlikely be accommodated. They must be flexible in attitude, with a good sense of humor, and able to adapt quickly to new and stressful situations. Please, seriously consider this information when giving your recommendation.
Does the applicant suffer or have a history of any of the following conditions? If so, please check and comment (explain) legibly. Please list medications for these problems if needed.
ASTHMA
CORONARY THROMBOSIS
DIABETES
DRUG, ALCOHOL, NARCOTIC ADDICTION
EPILEPSY
FOOD OR DRUG ALLERGIES or  INTOLERANCES (NAME THEM)
GASTRIC OR INTESTINAL DISORDERS
HIGH BLOOD PRESSURE
MENTAL DISORDER - DEPRESSION
PHYSICAL HANDICAP
NICOTINE ADDICTION 
STRESS
SYPHILIS
TUBERCULOSIS
NONE OF THE ABOVE_____OTHER__________________________________
I certify that the above applicant is in excellent health and physically and mentally fit. I see no obstacle to his or her participation. Please write legibly.
 _____________________________________________     _______________________________________ 
SIGNATURE OF PHYSICIAN                                               DATE (within last year prior to travel)
ADDRESS______________________________________TEL(___)__________________
Information which the applicant withholds from the physician or Bridges for Education makes the applicant wholly responsible for the state of his or her health while in this program. Applicants are encouraged not to apply if they have any restrictions that will hamper their effectiveness in this program.