Summer Emergency Contact Information Form
. Study Abroad Location and Program:
MBA Summer - Rome
MBA Summer - Madrid
India Summer - Undergraduate
KIIS Costa Rica
KIIS Mexico I
KIIS Mexico II
KIIS Montréal Internship
KIIS Paris I
KIIS Paris II
KIIS Slavic Europe
KIIS Spain I
KIIS Spain II
CCSA - Belize
CCSA - Hong Kong
CCSA - Early Ireland
CCSA - Late Ireland
CCSA - London Summer
CCSA - Scotland
CCSA - West Africa
Other (please fill in below)
Study Abroad Location and Program:
Other (please specify)
. Present address:
City, State, Zip Code:
. Present Phone Number (cell and home):
Present Phone Number (cell and home):
. Telephone Number Abroad:
Telephone Number Abroad:
. Passport Number:
I have my passport and this is the number:
I do not have my passport yet (explain why not):
. U.S. Health Insurance:
U.S. Health Insurance:
Insurance Telephone Number:
If you do not have US health insurance, write "none":
. In case of an emergency, I give my permission for Bellarmine University to contact:
In case of an emergency, I give my permission for Bellarmine University to contact:
Relation to Student:
Cell Phone Number:
Other Phone Number (write N/A if not applicable):
. Please list any medical conditions of which we should be aware. If none, please write "None."
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.
. Providing the following medical information for your BU Emergency Card is optional but STRONGLY RECOMMENDED for your own personal safety.
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.
Check out our
and create your own now!