Center for International Studies - Study Abroad

Study Abroad - Once Accepted
Study Abroad/Domestic Travel Assistant Form

Program Name/Location:
Faculty Directors:
Sponsoring Dept:

First name (as it will appear on your passport):
Make sure that you give us your official name, the one on your drivers license, passport, etc. If you give us a nickname, it will get printed on your plane ticket, and you could have serious problems at the airport.
Middle name:
Last name:
Gender:
Date of Birth (month/day/year):
Citizenship:
Your Status (UD undergrad, UD grad student, other... if "other," please specify your status):

Local Address:
City/State/Zip:
Local Phone #:
Cell Phone #:
Campus Email:

Home Address (if different from above):
City/State/Zip/Country:
Home Phone #:
Home Fax #:
Home Email:

In case of emergency during your program, contact:
Contact Name:
Relationship:
Complete Address (street, city, state, zip):
Daytime/Work Phone #:
Evening Phone #:

Are you currently under the care of a doctor on a regular basis for a chronic or ongoing condition? If yes, specify below:

Do you suffer from any medicinal allergies? If yes, use the space below to briefly but specifically explain your allergy, including the names of medication(s) you must not take. State the chemical composition, not the brand name:

While abroad, will you require any medication (e.g., for allergies, diabetes, epilepsy, etc.) on a regular or periodic basis? If yes, specify below. State the chemical composition, not the brand name:

Additional comments:

By submitting this form, you are affirming that all of the information you have given, and do give throughout is true, correct and complete.
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