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  5. Slovakia Co-op Survey
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Name:
   
 
 
 
Date of Birth:
   
 
 
 
Address:
   
 
 
 
Course of Study:
   
 
 
 
Do you smoke?
 
Yes
 
No
 
 
 
Can you drive?
 
Yes
 
No
 
 
 
Do you have any serious medical conditions?
 
Yes
 
No
 
 
 
If so, which?
   
 
 
 
Do you participate in any dangerous/extreme sports?
 
Yes
 
No
 
 
 
If so, which?
   
 
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