Study Abroad Health and Safety Form

CBU requires all students participating in study abroad or travel study trips to complete the following health and safety form. This information will only be used to ensure you receive appropriate care in the event of a medical emergency. It will not be disclosed to your professors, classmates, or anyone else without your permission.

1Health history > 2Emergency contact information
Study Abroad Program Name
Name Name First Last
Birthdate Birthdate / MM / DD YYYY
899 number
CBU Email Address
Today's date Today's date / MM / DD YYYY
Gender
Do you have any medical conditions (such as asthma, diabetes, seizures, recent injuries or surgeries, mental health conditions, etc.) that would be important to know about in case of an emergency?

Do you have any medical conditions (such as asthma, diabetes, seizures, recent injuries or surgeries, mental health conditions, etc.) that would be important to know about in case of an emergency? Yes No
If yes, please explain.
Are you allergic to any foods or medications?

Are you allergic to any foods or medications? Yes No
If yes, please explain.
Do you have any other known allergies?

Do you have any other known allergies? Yes No
If yes, please explain.
Do you take any prescription medications on a regular basis?

Do you take any prescription medications on a regular basis? Yes No
If yes, please list the name of each medication.
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Enter Your Email Address *

A special link to resume the form will be sent to your email address.