Travel Registry International Travel Registry 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:*StudentEmployeeProgram ParticipantFamily member of leaderPlease indicate your ID number:*Your Emergency Contact InformationPrimary Phone:*Mobile PhoneEmail:* Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code US Emergency ContactContact Name:*Relationship To You:*Contact Phone (Home)*Contact Phone (Mobile):Contact Phone (Other):Contact Email:* Health InsurancePlease 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:*Group Number:*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?*YesNo Trip Type*SelectUniversity-Led TripStudy AbroadSpring TermWork Related Travel 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 ProgramPlease provide contact information for the sponsoring institution and program you are attending.Name of Program:*Institution:*Contact Email:* Contact Phone:*Supervisor Name:*Time abroad:*Fall BreakFall TermWinter TermSpring BreakSpring TermSummerDestination CountryDestination Country:*Arrival Date:* Departure Date:* CitiesCity to be Visited:*Arrival Date:* Departure Date:* Local AccommodationsType of Lodging:*HotelHostelApartmentFamily HomeOtherAddress 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?*YesNo2nd CityCity to be Visited:*Arrival Date:* Departure Date:* Local AccommodationsType of Lodging:*HotelHostelApartmentFamily HomeOtherAddress 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?*YesNo3rd CityCity to be Visited:*Arrival Date:* Departure Date:* Local AccommodationsType of Lodging:*HotelHostelApartmentFamily HomeOtherAddress 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?*YesNo4th CityCity to be Visited:*Arrival Date:* Departure Date:* Local AccommodationsType of Lodging:*HotelHostelApartmentFamily HomeOtherAddress 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?*YesNo5th CityCity to be Visited:*Arrival Date:* Departure Date:* Local AccommodationsType of Lodging:*HotelHostelApartmentFamily HomeOtherAddress 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?*YesNo6th CityCity to be Visited:*Arrival Date:* Departure Date:* Local AccommodationsType of Lodging:*HotelHostelApartmentFamily HomeOtherAddress 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 InformationBeginning of your trip:* End of your trip:* Program Leader/Director:*
