Participant Emergency Contact Form

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

  • Study Program

  • Program Contact Information

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

  • Personal Data

  • 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.

  • 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.