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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