Travel Jan Term | Medical Release and Info All students traveling off-campus for Jan Term must complete this form. You may instead choose to fill out the form in person by visiting the Study Abroad office located at WCC 204. PERSONAL INFORMATIONStudent's Name (as it appears on passport) First Middle Last Email* Enter Email Confirm Email Permanent Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Date of Birth* MM DD YYYY Gender*Some countries recognize non-binary gender on the passports they issue. Please choose the gender your passport has listed for you.FemaleMaleNon-binaryCourse/Destination*(choose your Jan Term course)London (Banks/Everist)Tanzania (Baker/Fairley)Cuba (Olive/McKelva)Mediterranean (Tooley)Ghana (Akuoko/Mohammed)Greece (Wells)Guatamala (Duffey/Hoops)New York City (Dominick)East Asia (Landeck/Pitts)Panama (Garcia/Healy)Do you have a valid passport?*Your passport must be valid six months AFTER travel. If you need to renew your passport or apply for a new one, please go immediately to the Study Abroad office (WCC 204), and they will help you with the process.YesNo, but I've appliedNoPassport NumberIssuing CountryPlace of BirthDate of Issuance DD MM YYYY Date of Expiration DD MM YYYY Photo of PassportPlease upload a photo of the main page of your passport. (If unable to do this here, you must provide a copy to the Study Abroad office - WCC 204.)Accepted file types: jpg, gif, png, tif, pdf.PERSON TO NOTIFY IN CASE OF ILLNESS OR INJURYEmergency Contact Name* First Last Emergency Contact Relationship*Emergency Contact Phone*Emergency Contact Alternate PhoneAlternate Phone is:CellWorkEmergency Contact Email Enter Email Confirm Email Emergency Contact Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country MEDICATIONS AND MEDICAL INFORMATION For your safety, if you have any medical condition that the Study Abroad office and/or faculty sponsor should be aware of, please provide the information below:Do you take any medications on a continuing basis?YesNoPlease list medications and the purpose for which you take them.Do you carry epinephrine?YesNoDo you carry insulin?YesNoAre you allergic to any medications?YesNoPlease list any allergies to medications.Medical ConditionsPlease indicate any chronic health conditions or other health situation the Study Abroad office and your professor should be aware of. Neck, back, or shoulder pain or injury Frequent or unexplained dizziness or fainting Uncorrectable vision or hearing impairments High blood pressure and/or heart problems Allergy to bee/wasp stings Diabetes Asthma, allergies, or breathing difficulties Hypoglycemia Seizures Other (please describe) More InformationPlease provide additional relevant information about your health situation.Physician's Name & Phone #AUTHORIZATIONS AND AGREEMENTSPlease enter your AC I.D. number.*Authorization for medical service during off-campus Jan Term study.* INSURANCE: Austin College students studying abroad during January Term are required to have medical, medical evacuation and repatriation coverage while out-of-the-country. Austin College has arranged for group coverage through FrontierMEDEX. The cost of the coverage has been included in the total course fee billed to the student. I hereby authorize medical service to provide appropriate treatment for any illness or injury that may occur during off-campus study in which I am involved. I hereby authorize any emergency medical care provided by ambulance/hospital personnel that might become necessary. Agreement to provide itinerary.* Participant agrees to provide a travel itinerary to the individual listed as the emergency contact. Please type your name as it appears on your passport.*I understand that typing my name in this box and submitting this form constitutes a legal signature and that the information provided here is true to the best of my knowledge.
