Study Abroad Emergency Medical Treatment Information Form 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin with Part A – Insurance Information. Fill in your printed name, colleague ID number, and travel dates. Ensure you provide your health insurance provider's name, policy or ID number, and group number. Confirm whether your insurance provides international coverage by selecting 'Yes' or 'No'.
3. Move to Part B – Emergency Contact Information. Enter the primary emergency contact's name, address, city, state, zip code, relationship to you, and their phone numbers (home, cell, business). Repeat this for a secondary emergency contact.
4. In Part C – Medical Conditions and Medications, list any acute or chronic medical conditions. If none exist, enter 'N/A'. Similarly, document any known allergies and medications you are currently taking along with their purposes; if there are none, write 'N/A'.
5. Finally, sign and date the form at the bottom to confirm that all information is accurate.

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