Emergency Contact Form - Outbound Students (14-15 & 15-16)

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* 1. Name:

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* 2. Study Abroad Location and Program:

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* 3. Present address:

Street:

City, State, Zip Code:

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

Cell:

Home:

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* 5. Telephone Number Abroad:

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* 6. Passport Number:

I have my passport and this is the number:

I do not have my passport yet (explain why not):

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* 7. U.S. Health Insurance:

Provider Name:

Policy Number:

Group Number:

Insurance Telephone Number:

If you do not have US health insurance, write "none":

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

Name: *

Relation to Student: *

Address:

City/State/ZIP:

Cell Phone Number: *

Other Phone Number (write N/A if not applicable):

Email Address: *

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

Allergies:

Blood type:

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* 10. 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.

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

Please submit your form by clicking "Done" below. We do not need a printed copy of this form.