Medical Emergency Contact Form by 7Bhb5r

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									                                  MEDICAL EMERGENCY CONTACT FORM

Because studying abroad can be quite rigorous and demanding, we believe that only those students who are in good
physical and mental health should plan to participate. For this reason we ask that the student and/or his/her parent
or legal guardian carefully read, and then sign and date the following certification.

“I certify that I am in good physical and mental health, and that I do not suffer from any mental or
physical problem or condition that would prevent me from successfully taking part in a rigorous
study abroad program

at___________________________________________.

I further understand and agree that, in the event of an emergency abroad, Clark University reserves
the right to notify my parent(s) or guardian(s) as listed by me as “Emergency Contact Person(s) on
this form.”



STUDENT NAME
                                                                                      MARRIED
        DOB                              NATIONALITY
                                                                                      /SINGLE

     HOME
    ADDRESS



EMERGENCY CONTACT PERSON(S):

Name:
Phone Number (HOME):
Phone Number (WORK):
Cell Phone Number:
Email address:
FAX Number:

Address:



IMPORTANT: You are required to have medical insurance for your entire time abroad. Be aware
that most insurance policies in the U.S. are of the refundable variety; that is, you pay the doctor
and/or hospital overseas, save the receipts, and return these to your insurance company for
reimbursement. Please insure that you have extra cash on hand or a credit card for medical
emergencies. If possible, take along your insurance company’s claim forms. Consider some
supplementary emergency medical coverage if your insurance policy does not include emergency
medical evacuation and repatriation benefits (for example SOS Assistance, or HTH Worldwide).
Information on these types of policies is available in the Study Abroad Office.

								
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