Pace University Travel Course Medical Information Form printable pdf download

Pace University

Travel Course

Medical Information Form

This form is to be completed by the participant. The purpose of this form is to enable Pace University to

provide appropriate assistance to you should the need arise during your study abroad/travel course

experience. It is important that we be aware of any medical or emotional problems, past or current,

which might affect your ability to participate in the study abroad program. Please be honest and

comprehensive. The information provided will remain confidential as allowed by law and will not be

used to disqualify you from the program. Relevant information will be shared with program staff,

faculty, or appropriate professionals as it relates to your health and safety. Pace University shall not be

responsible for participant’s failure to provide complete and accurate information.

Student’s Name: ______________________________________ Pace ID#: __________________

Date of Birth: _______________ Cell Phone:___________________________

Name of Travel Course:________________________________________________________________

Travel Destinations:____________________________Dates of Program: _______________________

This information is required to coordinate treatment in the event of a medical emergency. If you answer

YES to any of the following questions, please provide details of the condition and treatment you

received or are continuing to receive. Please contact us if any conditions or treatments change before the

start of your program.

Are you currently under medical treatment? □Yes □ No If yes, explain.

Are there any medical conditions that we should be made aware of? □Yes □No If yes, explain.

Do you suffer from any allergies? □Yes □No If yes, explain.

Are you currently taking any medications? □Yes □No If yes, please specify.

Are you allergic to any medication? □Yes □No If yes, explain.

Do you suffer from any food allergies or have any dietary restrictions? □Yes □No If yes, explain.

Pace University –International Office

Updated 02/23/10

Pace University Travel Course Medical Information Form