995 lir 616. BCG 06/05/1989 yy 617. Hepatitis B 10/21/2003 Ce 618. Other Rubella, Measles, Mumps, General medical questions 621. Blood group and Rhesus factor (if known 622. Any post ilness. operations. serious accidents ? none Specify which onefsl: 623. Any physical or mental disabilities? none

case (below) so as to cover emergencies. as the hospitals generally demand a large deposit. To be completed by the cardholde 621. Blood group and Rhesus factor (if known): By signing at the bottom of this page. I hereby authorise Institut Vila Pierrefeu S.A. (the school) to debit my card to cover