Emergency Contact Form | Study Abroad | International Division

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Passport | Insurance | Emergency Contact | Advisor

This form is intended to obtain passport, insurance, emergency contact and advisor information for all students attending University of Indianapolis Approved Study Abroad Programs.

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 University of Indianapolis Student
Yes No If No, what is your home institution?

* Student Level
Undergraduate Graduate

Time abroad.

*Term(s) you wish to study abroadSelect all that apply
Fall Spring Summer Other If Other, please specify

*Calendar year(s) you wish to study abroad Example:2008 or 2008 to 2009

Study Program
*Study Abroad / Spring Term
Program 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

Advisor Info
Freshmen, please enter TBD in each advisor field.

*Home School Advisor Name *Advisor Department *Advisor Phone *Advisor E-mail *Re-type Advisor E-mail, to confirm

Personal Data
*Student Surname (As on Passport) *Student First Name (As on Passport) *Student Middle Name or Initial (As on Passport) *Primary Student E-mail *Re-type Primary Student E-mail, to confirm Secondary Student E-mail Re-type Secondary Student E-mail, to confirm

*Gender
Male Female

*Date of Birth Format: m/d/yyyy *City of Birth *State / Region / Province of Birth *Country of Birth

Health Insurance Details

During my enrollment in UIndy Study Abroad/Spring Term, 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 study abroad/spring term 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

Student 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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