<p> BUENA VISTA UNIVERSITY MEDICAL INFORMATION, INSURANCE CERTIFICATION AND AUTHORIZATION/RELEASE FOR FOREIGN TRAVEL I. GENERAL Name:______Date of Birth:______</p><p>Phone:______Email:______</p><p>Passport Number:______Passport Expiration Date:______</p><p>II. PERSONAL MEDICAL HISTORY - Comment on all positive answers under remarks.</p><p>HAVE YOU HAD Yes HAVE YOU HAD Yes</p><p>Allergy to: Surgery or serious injury</p><p>Penicillin Chronic medical condition - specify</p><p>Sulfonamides Vision, corrective lens</p><p>Peanuts Cancer</p><p>Bees, wasps Heart disease</p><p>Other Serious head injury</p><p>Specify: Hepatitis B</p><p>Hepatitis C</p><p>Kidney disease</p><p>Infectious mononucleosis Neurological disorder</p><p>Tropical disease - specify Depression/anxiety</p><p>Chicken pox/Varicella Other psychological problem</p><p>Respiratory disorders including asthma Seizure disorder</p><p>High blood pressure Organ loss</p><p>Diabetes, thyroid, endocrine problems H1N1 Flu Vaccine</p><p>Stomach or intestinal disorders Seasonal Flu Vaccine</p><p>Blood disorders including anemia</p><p>Headaches/migraines</p><p>Menstrual cycle disorders</p><p>Current prescription medicines - list Current non-prescription medicines - list REMARKS OR ADDITIONAL INFORMATION:______</p><p>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</p><p>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:______</p><p>III. HEALTH INSURANCE INFORMATION REQUIRED</p><p>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.</p><p>Name of Company______Certificate Number______</p><p>I certify the above is true and correct.</p><p>IV. MEDICAL AUTHORIZATION</p><p>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.</p><p>V. PERMISSION TO RELEASE INFORMATION</p><p>In case of emergency while I am abroad, I authorize BVU or it agents to contact and share information, without restriction, with:</p><p>1. Name______Relationship______</p><p>Address______Phone Cell Fax Email</p><p>2. Name______Relationship______</p><p>Address______</p><p>______Phone Cell Fax Email VI. RELEASE</p><p>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.</p><p>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.</p><p>* * * * * * * * * * * * * * * * * * * * * * * * *</p><p>If you are younger than 18 years of age, a parent’s signature is required. </p><p>______Signature Printed Name Date</p>