Participant Emergency Contact Form

This form is intended to obtain insurance and emergency contact information for all those participating in University of Indianapolis international 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.
Time Abroad
Time Abroad*
Date(s) you wish to study abroad*
MM
DD
YYYY
Study Program
Study Abroad / Short Term Program you will be attending*
Program Contact Information

Please provide contact information for the sponsoring institution and program you are attending, or trip leader.
Institution / Trip*
Contact Name*
First Last
Contact Phone*
Contact Email*
Re-type Contact Email, to confirm*
Personal Data
Full Name (As on Passport)*
First Middle Last
Email*
Re-type Email, to confirm*
Insurance Details
During my participation in this UIndy Study Abroad/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.
Insurance Company*
Insurance Company Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Insurance Company Phone
Insurance Policy Number
Insurance Group
Emergency Contact Person Details
Who we can contact in the US while you are abroad
Emergency Contact Name*
First Last
Relationship to you*
Emergency Contact Phone*
Emergency Contact Mobile
Emergency Contact Other Phone/Mobile
Emergency Contact Email
Emergency Contact Re-type Email
Your Emergency Details
How we can contact YOU while you are abroad

Please include country codes for non-US numbers.
Phone*
Mobile
Email
Re-type Email

Participant Emergency Contact Form

Time Abroad

Study Program

Personal Data

Insurance Details

Emergency Contact Person Details

Your Emergency Details

University of Indianapolis