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New Majors: Engineering

UIndy now offers majors in Software Engineering and Industrial & Systems Engineering.
Learn more about our engineering programs ►
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Step 1 of 4

25%

First Name (As on Passport):*
Last Name (As on Passport):*
Middle Name or Initial (As on Passport)
Your Primary Relationship to UIndy:*
- Student
- Employee
- Program Participant
- Family member of leader
Please indicate your ID number:*
Your Emergency Contact Information
Primary Phone:*
Mobile Phone
Email:*
Address*
Street Address City State ZIP Code

US Emergency Contact
Contact Name:*
Relationship To You:*
Contact Phone (Home)*
Contact Phone (Mobile):
Contact Phone (Other):
Contact Email:*

Health Insurance
Please provide the contact name and information of your health insurance provider.
Company Name:*
Insurance Company Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Insurance Company Phone*
Policy Number:*
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Note: All travelers to international destinations must have valid coverage for Medical Evacuation and Repatriation. If your insurance company does not provide this coverage, you may purchase it separately through various vendor available online. Have you purchased this coverage separately?*
- Yes
- No

Trip Type*
University-Led Trips include conference, educational trips, or any trip in which you are representing the university in a formal or informal way.

Spring Term Trips: select this option if you are leading, co-leading, or are part of an International Spring Term trip.
Institution and Program
Please provide contact information for the sponsoring institution and program you are attending.
Name of Program:*
Institution:*
Contact Email:*
Contact Phone:*
Supervisor Name:*
Time abroad:*
Destination Country
Destination Country:*
Arrival Date:*
Departure Date:*
Cities
City to be Visited:*
Arrival Date:*
Departure Date:*
Local Accommodations
Type of Lodging:*
- Hotel
- Hostel
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Address at this Location:*
International Contact Information:
Please note, if you are using a U.S. mobile with an international plan, your country code is 001.
Country Code:*
City Code:*
Number:*
Emergency Contact at Location:
Name:*
Phone Number:*
Address:*
Do you want to add another city?*
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2nd City
City to be Visited:*
Arrival Date:*
Departure Date:*
Local Accommodations
Type of Lodging:*
- Hotel
- Hostel
- Apartment
- Family Home
- Other
Address at this Location:*
Local Contact Information:
Please note, if you are using a U.S. mobile with an international plan, your country code is 001.
Country Code:*
City Code:*
Number:*
Emergency Contact at Location:
Name:*
Phone Number:*
Address:*
Do you want to add another city?*
- Yes
- No
3rd City
City to be Visited:*
Arrival Date:*
Departure Date:*
Local Accommodations
Type of Lodging:*
- Hotel
- Hostel
- Apartment
- Family Home
- Other
Address at this Location:*
Local Contact Information:
Please note, if you are using a U.S. mobile with an international plan, your country code is 001.
Country Code:*
City Code:*
Number:*
Emergency Contact at Location:
Name:*
Phone Number:*
Address:*
Do you want to add another city?*
- Yes
- No
4th City
City to be Visited:*
Arrival Date:*
Departure Date:*
Local Accommodations
Type of Lodging:*
- Hotel
- Hostel
- Apartment
- Family Home
- Other
Address at this Location:*
Local Contact Information:
Please note, if you are using a U.S. mobile with an international plan, your country code is 001.
Country Code:*
City Code:*
Number:*
Emergency Contact at Location:
Name:*
Phone Number:*
Address:*
Do you want to add another city?*
- Yes
- No
5th City
City to be Visited:*
Arrival Date:*
Departure Date:*
Local Accommodations
Type of Lodging:*
- Hotel
- Hostel
- Apartment
- Family Home
- Other
Address at this Location:*
Local Contact Information:
Please note, if you are using a U.S. mobile with an international plan, your country code is 001.
Country Code:*
City Code:*
Number:*
Emergency Contact at Location:
Name:*
Phone Number:*
Address:*
Do you want to add another city?*
- Yes
- No
6th City
City to be Visited:*
Arrival Date:*
Departure Date:*
Local Accommodations
Type of Lodging:*
- Hotel
- Hostel
- Apartment
- Family Home
- Other
Address at this Location:*
Local Contact Information:
Please note, if you are using a U.S. mobile with an international plan, your country code is 001.
Country Code:*
City Code:*
Number:*
Emergency Contact at Location:
Name:*
Phone Number:*
Address:*
Trip Information
Beginning of your trip:*
End of your trip:*
Program Leader/Director:*

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Indianapolis, Indiana 46227
317-788-3368 • 800-232-8634

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