Pace University Travel Course Medical Information Form (Page 2 of 2) in pdf

Do you have a disability that will require accommodations while abroad? □Yes □ No If yes, explain.

Please be advised that the Americans with Disabilities Act (ADA) does not apply outside the borders of

the U.S. However, Pace will assist you, to the extent possible, but we may not be able to obtain the

accommodations necessary to enable you to participate in all aspects of the overseas program.

Additional Health Conditions

Do you have any additional health conditions other than those previously listed (such as surgeries,

hospitalizations, injuries, chronic conditions, physical illness, psychological illness, emotional illness,

mental illness, etc.) that may need special consideration before or during your experience or may affect

your ability to participate in this program?

Yes

No If Yes, explain:

If “Yes” above, you are required to fill out your Physician’s contact details below. In addition and you

are advised to consult with your health care provider.

Physician’s Name:

__________________________________________________________________

Physician’s Address: __________________________________________________________________

Physician’s Phone #: __________________________________________________________________

Emergency Contact Information: Person to notify in case of emergency, illness or accident:

Name:______________________________________ Relationship to students:__________________

Street/Apt#__________________________________ Cell Phone:______________________________

City, State, Zip_______________________________ Home Phone:____________________________

E-mail address:_______________________________

Authorization Statement:

I hereby authorize the release of information from my medical history upon the request of Pace University’s

Office of International Programs & Services. I certify that the information on this Medical Information Form is

true and correct, and I will notify Pace University’s Office of International Programs & Services hereafter of any

relevant changes in my health that occur prior to the start of the program. I understand that this information will

be used only for the purposes for which it was prepared.

I authorize Pace, its employees, agents and representatives to act in any attempt to safeguard and preserve my health

and/or safety during my participation in the program, including authorizing medical treatment on my behalf and at

my expense, and returning me to the United States at my own expense for medical treatment in case of an

emergency.

Signature: ______________________________________ Date: _____________________________

Pace University –International Office

Updated 02/23/10

Pace University Travel Course Medical Information Form Page 2