Emergency Contact & Medical Information Form

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


Participant's Emergency Contact Information

Middle Name:
Suffix:
Semester/Year Abroad Program or Study/Travel Course Number/Title (the "Program"):*This is a required field.
Passport Number (NOTE: If your passport number is unknown, please return to this form no later than the deadline listed on the OIE website.):*This is a required field.
Address Line 2:
Cell Phone Number (including the area code):*This is a required field.
R-MC E-mail Address:*This is a required field.
Non R-MC E-mail Address:*This is a required field.

Emergency Contact Information

Contact Relationship:*This is a required field.
Contact Address Line 1:*This is a required field.
Contact Address Line 2:
Nighttime Phone:*This is a required field.
2nd Contact Name:*This is a required field.
2nd Contact Relationship:*This is a required field.
Contact Address Line 1:*This is a required field.
Contact Address Line 2:
Nighttime Phone:*This is a required field.
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.

Electronic Signature:
Date:
08-29-2016

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:

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

(If no, indicate "N/A")
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:*This is a required field.

(If no, indicate "N/A")
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")
4. Do you take any prescription medicines on a regular basis? If so, list them:*This is a required field.

(If no, indicate "N/A")
5. Do you take any over-the-counter (non-prescription) medicines on a daily basis? If so, list them:*This is a required field.

(If no, indicate "N/A")
6. Do you have any other life-threatening allergies, e.g., peanuts, chocolate, seafood, bee stings? If so, list them:*This is a required field.

(If no, indicate "N/A")
7. Are you currently being treated for any medical conditions or illnesses that you have not listed above? If so, list them:*This is a required field.

(If no, indicate "N/A")
8. Do you wear contact lenses?*This is a required field.

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:*This is a required field.

(If no, indicate "N/A")


Electronic Signature:*This is a required field.


Date: 08-29-2016

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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