* 1. Name:

* 2. Study Abroad Location and Program:

* 3. Present address:

* 4. Present Phone Number (cell and home):

* 5. Telephone Number Abroad:

* 6. Passport Number:

* 7. U.S. Health Insurance:

* 8. In case of an emergency, I give my permission for Bellarmine University to contact:

* 9. Please list any medical conditions of which we should be aware. If none, please write "None."

Please explain in detail. Failure to disclose these medical conditions may result in removal from the program. This is important for the International Programs Office and the program coordinators to know for your health and well being while abroad. A doctor's letter releasing you to participate may be requested.

* 10. Providing the following medical information for your BU Emergency Card is optional but STRONGLY RECOMMENDED for your own personal safety.

Information provided in questions 8 - 10 will be listed on your Bellarmine Emergency Card.