Faculty and Staff Emergency Contact Form

This form is intended to obtain insurance and emergency contact information for all faculty and staff leading 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(n)
Time abroad

Example: 8/29/2011 to 5/4/2012

Trip
*Term
Personal Information
Insurance Details

During my participation in this international short-term trip, I will be covered by the following 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