R-MC Study/Travel Courses and Semester/Year Abroad Programs
Emergency Contact & Medical Information Form
Participant's Emergency Contact Information
Emergency Contact Information
I do not elect to share any information including that I am a participant in the Program with the following individual(s):*This is a required field.
Full name(s) of the individual(s) and relationship(s):
(If none, indicate "N/A")
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.
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.
If you DO elect to provide medical information, please continue with the following questions:
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:*This is a required field.
(If no, indicate "N/A")
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.