BUENA VISTA UNIVERSITY MEDICAL INFORMATION, INSURANCE CERTIFICATION AND AUTHORIZATION/RELEASE FOR FOREIGN TRAVEL I. GENERAL Name:______Date of Birth:______

Phone:______Email:______

Passport Number:______Passport Expiration Date:______

II. PERSONAL MEDICAL HISTORY - Comment on all positive answers under remarks.

HAVE YOU HAD Yes HAVE YOU HAD Yes

Allergy to: Surgery or serious injury

Penicillin Chronic medical condition - specify

Sulfonamides Vision, corrective lens

Peanuts Cancer

Bees, wasps Heart disease

Other Serious head injury

Specify: Hepatitis B

Hepatitis C

Kidney disease

Infectious mononucleosis Neurological disorder

Tropical disease - specify Depression/anxiety

Chicken pox/Varicella Other psychological problem

Respiratory disorders including asthma Seizure disorder

High blood pressure Organ loss

Diabetes, thyroid, endocrine problems H1N1 Flu Vaccine

Stomach or intestinal disorders Seasonal Flu Vaccine

Blood disorders including anemia

Headaches/migraines

Menstrual cycle disorders

Current prescription medicines - list Current non-prescription medicines - list REMARKS OR ADDITIONAL INFORMATION:______

Are you capable of participation in a full program of activities? ______Yes______No Is there anything additional about your health that we should know? ______Yes______No

Are you now under treatment with medication for any medical or emotional condition? ______Yes______No If “yes,” please explain______Do you have a disability that may require an academic or another type of accommodation to enable you to participate in this program? ______Yes______No If “yes,” please explain nature of disability and accommodation required:______

III. HEALTH INSURANCE INFORMATION REQUIRED

Insurance Coverage. All students traveling abroad must be covered by a health insurance policy for the duration of their proposed overseas stay. The policy shall include coverage of illnesses and accidents, with no declination for pre-existing medical problems and medical evacuation and repatriation.

Name of Company______Certificate Number______

I certify the above is true and correct.

IV. MEDICAL AUTHORIZATION

I authorize BVU or its agents to secure medical treatment on my behalf in the event of a health emergency, and I accept financial responsibility for such medical treatment. I also authorize BVU or its agents to release medical information contained in this file to a care provider in the event of a health emergency, or as needed to provide reasonable accommodations.

V. PERMISSION TO RELEASE INFORMATION

In case of emergency while I am abroad, I authorize BVU or it agents to contact and share information, without restriction, with:

1. Name______Relationship______

Address______Phone Cell Fax Email

2. Name______Relationship______

Address______

______Phone Cell Fax Email VI. RELEASE

In consideration and as a condition of my being permitted to participate in the Program, I personally assume all risks incident to the Program and its activities. I also waive, release and forever discharge, and agree to indemnify and hold harmless, BVU, its trustees, employees and agents from all liabilities, losses, damages, claims, actions, causes of action, demands or costs of any nature whatsoever that may arise in connection with my travel to and/or participation in the program (including rescue activities associated with such travel or the program), whether caused by BVU, its employees or agents or caused by some other means. I hereby agree not to file suit against BVU, its trustees, employees or agents, or any of them, in connection with or as a result of my participation in the program. Neither BVU nor the program shall be responsible for any loss or theft of, or any damage to, any of my personal property, including without limitation airline tickets, passports, visas, travel documents or currency, irrespective of when such loss, theft or damage shall occur. The terms of this document shall bind me, my heirs, beneficiaries, assigns and personal representatives.

Prior to signing this document, I have had an adequate opportunity to read and understand it, have had an opportunity to ask questions about it, and any questions I have had have been answered to my satisfaction. I further state that I am ______years old and competent to sign this document.

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If you are younger than 18 years of age, a parent’s signature is required.

______Signature Printed Name Date