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Questionnaire for Participation in Study Abroad
Date
(Required)
MM slash DD slash YYYY
Student Name
(Required)
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#
(Required)
Email Address (so we can notify you when your form is ready for pickup).
(Required)
Name of Study Abroad Program/Country:
(Required)
Do you have asthma or have you ever experienced an induced asthma attack?
(Required)
No
Yes
Do you have any known allergies to food, plants, insect stings, bites, or animal hair?
(Required)
No
Yes
Do you take any medications on a regular basis?
(Required)
No
Yes
Do you have any other condition(s) that might compromise your ability to fully participate in a study abroad program?
(Required)
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:
Captcha
Name
This field is for validation purposes and should be left unchanged.