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.
Program Contact Information
Please provide contact information for the sponsoring institution and program you are attending, or trip leader.
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.
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.