Student Emergency Contact,
Information for Trips Abroad

This form is intended to obtain insurance and emergency contact 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
* Student Level
Time abroad
*Term(s) you wish to study abroadSelect all that apply






Example: 8/29/2011 to 5/4/2012
Study Program
Program Contact Information Please provide contact information for
the sponsoring institution and program you are attending

Personal Data


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.

Emergency Contact Person Details
- Who we can contact in the US while you are abroad

Your Emergency Details
- How we can contact YOU while you are abroad

 

Please include country codes for non-US numbers

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