Emergency Contact & Medical Information Form

R-MC Study/Travel Courses and Semester/Year Abroad Programs Emergency Contact & Medical Information Form


Participant's Emergency Contact Information

Last Name:*  
First Name:*  
Middle Name:
Suffix:
Preferred Name:*  
Semester/Year Abroad Program or Study/Travel Course Number/Title:*  
Passport Number (NOTE: If your passport number is unknown, please return to this form no later than the deadline listed on the OIE website.):*
 
Street Address:*  
City and State:*  
Zip Code:*  
Cell Phone Number:*  
R-MC E-mail Address:*  
Non R-MC E-mail Address:*  

Emergency Contact Information

Contact Name:*
Contact Relationship:*
Contact Address:*
Daytime Phone:*
Nighttime Phone:*
Cell Phone:*
E-mail Address:*
2nd Contact Name:*
2nd Contact Relationship:*
Contact Address:*
Daytime Phone:*
Nighttime Phone:*
Cell Phone:*
E-mail Address:*

Emergency Medical Information


It is important for medical personnel to have certain information about you, should you need to obtain emergency medical treatment. Participants in study/travel courses and semester/year abroad programs offered through Randolph-Macon College are encouraged to provide the information requested on this form. The information will be shared with your faculty instructor(s) confidentially and only used in case of emergency. Upon completion of your study/travel course or semester/year abroad program, the data submitted via this form will be destroyed by the Office of International Education.

1. Are you allergic to any medications (prescription or non-prescription)? If so, list all medications to which you are allergic*:


2. Do you have any medical conditions that health care personnel should know of, in case you need to receive emergency medical treatment (such as, but not limited to, asthma, diabetes, epilepsy, or a heart condition)? If so, list your medical conditions*:


3. Have you had any previous surgeries (e.g., appendectomy), injuries (e.g., fractures, serious head trauma), or major illnesses (e.g., pneumonia, cancer), or any illness that required hospitalization? If so, list them*:


4. Do you take any prescription medicines on a regular basis? If so, list them*:


5. Do you take any over-the-counter (non-prescription) medicines on a daily basis? If so, list them*:


6. Do you have any other life-threatening allergies, e.g., peanuts, chocolate, seafood, bee stings? If so, list them*:


7. Are you currently being treated for any medical conditions or illnesses that you have not listed above? If so, list them*:


8. Do you wear contact lenses?*


9. OTHER: Is there any other information, not addressed above, that you would want made available to medical personnel, should you need to receive emergency medical treatment, e.g., religious restrictions regarding medical care? If so, list the information here*





Electronic Signature:*


Date: 08-30-2015

By signing this form, you do affirm that you are the person whose electronic signature appears above and that all information provided within this form is true and accurate.


I elect NOT to provide the medical information requested on this form.
Electronic Signature:

Date: 08-30-2015

By signing this form, you do affirm that you are the person whose electronic signature appears above and that all information provided within this form is true and accurate.


A parent's signature is required only if the student will be under eighteen (18) years of age during the period of travel.

This signature is only required if the applicant is under 18.
Electronic Signature:*


Date: 08-30-2015

By signing this form, you do affirm that you are the person whose electronic signature appears above and that all information provided within this form is true and accurate.

ATTENTION: These forms are not completely submitted until you see the submission confirmation on the next page.

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