Student Health/Emergency Treatment Authorization

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Complete

Which of the following will you be participating in?

Retreat

Immersion experience

Study abroad

The medical review of this form and admission into a program are independent of each other. The purpose of this form is to help �ۿ۴�ý University provide appropriate assistance to you should the need arise during your program experience away from campus.

It is important that we be aware of any medical problems (past or current), including mental health conditions, which might affect your ability to participate in a �ۿ۴�ý program. This information will be kept confidential in accordance with the law. Any disclosure of such information will be made only to appropriate individuals, and handled with the highest level of discretion in order to protect student privacy. Relevant information will be shared with program staff, leaders, or appropriate professionals as it relates to your health and safety. Failure to disclose significant health issues may result in dismissal from the program.

Health tests or immunizations may be required prior to departure in certain circumstances.

Name

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	First	Last	Item weight

Date of birth

Current address

Street Address

City

State / Province / Region

ZIP / Postal Code

Country

Cell phone

Phone format: (###) ###-####

Home phone

Phone format: (###) ###-####

Name of retreat

Location of immersion experience

Location of program

Start Date

End Date