Emergency Contact Form | Faculty Led | International Division

Emergency Contact Information for Faculty Led Courses & Trips

This form is intended to obtain passport, insurance and emergency contact information for all University of Indianapolis Faculty Led Courses & Trips.

Fields marked with an asterisk * are required. If any required fields are left blank, your form will not be submitted – you will be asked to go back and complete the required fields.

General Information

* I am a Program Participant
of a University of Indianapolis
Faculty Led Course/Trip.
Yes No What is your designation for this Course/Trip?

Time abroad

*Term you will be participating in

*Calendar year(s) Example:2008 or 2008 to 2009

Study Program
*Faculty Led Course/Trip
you will be attending Program Contact Information Please provide contact information for
the sponsoring institution or program you are attending

*Institution Name *Contact Name *Contact Phone *Contact E-mail *Re-type Contact E-mail, to confirm

Personal Data
* Surname (As on Passport) * First Name (As on Passport) * Middle Name or Initial (As on Passport) *Primary E-mail *Re-type Primary E-mail, to confirm Secondary E-mail Re-type Secondary E-mail, to confirm *Date of Birth Format: m/d/yyyy *City of Birth *State / Region / Province of Birth *Country of Birth

Health Insurance Details

During my participation in University of Indianapolis Faculty Led Course/Trip, I will be covered by the following Health, Accident, and Hospitalization Insurance:
Please provide the contact name and information that will provide you with required international coverage.

Insurance Company Insurance Company Address Insurance Company Phone Insurance Policy Number Insurance Group

Citizenship and Passport Details

If you have citizenship in more than one country and carry multiple passports, please provide data only for the passport that you will use to enter and depart from your Faculty Led Course/Trip city (ie, the passport that contains your visa, where required.) If you have dual or multiple citizenships, we ask that you list them in the relevant fields below, but you are not required to provide specific information for additional passports.

*Primary Citizenship/ Country
that issued your passport Authority/Agency that issued your passport *Passport Number *Date of Issue Format: m/d/yyyy *Date of Expiration Format: m/d/yyyy

I have citizenship in other country(s) No Yes If Yes, please list country name(s) here

Participants' Permanent Contact Numbers

Please include country codes for non-US numbers

*Permanent Phone Permanent Mobile Other Phone/Mobile

Emergency Contact Details
*Emergency Contact Name *Relationship to you

Please include country codes for non-US numbers

*Emergency Contact Primary Phone Emergency Contact Phone, Other Emergency Contact E-mail Address Re-type Emergency Contact E-mail
Address, to confirm *Emergency Contact Address

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