R-MC Study/Travel Courses and Semester/Year Abroad Programs
Emergency Contact & Medical Information Form
Participant's Emergency Contact Information
Emergency Contact Information
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*
A parent's signature is required only if the student will be under eighteen (18) years of age during the period of travel.
ATTENTION: These forms are not completely submitted until you see the submission confirmation on the next page.