Questionnaire for Participation in Study Abroad

Date*
Date Format: MM slash DD slash YYYY
Student Name*
This acts as your legal and binding signature and indicates that all of the information provided is factual to the best of your knowledge.
Student ID / T#*
Email Address (so we can notify you when your form is ready for pickup).*
Name of Study Abroad Program/Country:*
Do you have asthma or have you ever experienced an induced asthma attack?*
- No
- Yes
Do you have any known allergies to food, plants, insect stings, bites, or animal hair?*
- No
- Yes
Do you take any medications on a regular basis?*
- No
- Yes
Do you have any other condition(s) that might compromise your ability to fully participate in a study abroad program?*
- No
- Yes
Females Only: Are you pregnant? If you are pregnant, clearance must be obtained through your Ob/Gyn.
- Yes
- No
Females Only: Date of last menses:
Name
This field is for validation purposes and should be left unchanged.