EAST TENNESSEE STATE UNIVERSITY

Work Phone:

Insurance Carrier:

Policy Number:

Sweden Classes Summer 2008

July 7 - August 8

EAST TENNESSEE STATE UNIVERSITY

HEALTH DISCLOSURE

In the event of any medical emergency (physical or mental), Student hereby grants to East Tennessee State University or any of its representatives on the Program the full authority to take any action deemed necessary to protect Student’s mental or physical health and safety at Student’s own expense, including, but not limited to, placing Student under the care of a doctor or in a hospital or any place for medical examination and/or treatment or returning the Student to the United States at Student’s own expense if such return is deemed necessary after consultation with medical authorities. In the event Student is returned to the United States, Student shall not recover any money paid for and in connection with the Program. Student agrees East Tennessee State University is not required to take any such actions if it is not aware of the emergency or in its discretion determines no emergency exist. Should the need arise, East Tennessee State University is authorized to provide any personal information of Student to any health care provider.

Please read these forms and follow all instructions for completion. FULL DISCLOSURE REQUIRED. The information on these forms will assist health care providers in the event of a medical emergency. It is very important that all sections are completed fully and accurately. If a question is not applicable, enter N/A.

STUDENT NAME:

HOME ADDRESS:

CITY:	STATE:		ZIP:

MAILING ADDRESS:

CITY:	STATE:		ZIP:

HOME PHONE:		WORK PHONE:

First Emergency Contact:

Name:			Relationship:

Address:

City:	State:			Zip:

Home Phone:		Work Phone:

Second Emergency Contact:

Name:			Relationship:

Address:

City:	State:			Zip:

Home Phone:		Work Phone:

Primary Care Physician:

Medical insurance is required for course participation.

Medical History

ALL QUESTIONS MUST BE ANSWERED. FOR EACH "YES" PROVIDE AN EXPLANATION

IN THE AREA PROVIDED BELOW. ATTACH AN ADDITIONAL SHEET IF NECESSARY.

Do you currently have or have you ever had a history of:	NO	YES
Allergies to foods?
Allergies to medication?
Altitude sickness?
Anaphylactic reactions?
Arthritis?
Bleeding disorders?
Cardiac/circulatory problems?
Chemical abuse or dependency? (drugs, alcohol, etc.)
Diabetes?
Eating disorders including anorexia and/or bulimia?
Endocrine problems?
Epilepsy?
Frostbite or abnormal intolerance to cold temperatures?
Gastrointestinal problems?
Heat exhaustion/heat stroke or abnormal intolerance to hot temperatures?
Hypertension?
Knee, ankle, back or other skeletal problems including, but not limited to sprains, fractures or operations?
Liver dysfunction?
Lymphatic problems?
Menstrual cramps?
Muscular problems?
Neurological problems?
Premenstrual syndrome?
Psychiatric treatment or psychological counseling?
Reproductive organ problems?
Respiratory problems including, but not limited to asthma, chronic bronchitis or allergies?
Thyroid problems including allergy to iodine?
Urinary tract disorders?
Are you currently pregnant?
Are you currently seeing a doctor or health specialist?
Are you currently taking any non- prescription medications?
Are you currently taking any prescription medications?
Do you have any dietary restrictions?
Do you wear contact lenses?

PLEASE USE THIS SPACE TO COMPLETELY EXPLAIN ALL YES ANSWERS. USE A

SEPARATE SHEET OF PAPER IF NECESSARY. LIST ALL MEDICATIONS. ADVISED THAT

SOME MEDICAL CONDITIONS MAY REQUIRE A DOCTOR’S APPROVAL FOR PARTICIPATION IN THIS COURSE.

I verify that all information provided in this health disclosure is complete, accurate and true to the best of my knowledge.

Signature:

Print Name:		Date:

STUDY ABROAD ITINERARY REQUIREMENTS

(SAMPLE)

Trip Day	Date	Transportation		Lodging		Meals Included			Site Plans	Other: Indicate by Day
		Type	From -To	No.	City	B=Brkfast	L=Lunch	D=Dinner
1	May18, 2000	Air	Houston to		Overnight flight		On flight
2	May 19	Bus	Gatwick to London	1	London – First Class hotel, centrally located	Full breakfast		3 course dinner	3 hour private bus tour of London with guide, including guided visit to Westminster Abbey and St. Paul’s Cathedral	All entrance fees included; a three day subway (tube) pass included
3	May 20	Tube	London	2	London – Same hotel	Full breakfast		3 course dinner	Guided visit to the Globe Theater; two hour guided visit to Tower of London; Evening theater performance at the Globe	All entrance fees and theater tickets (2^nd balcony seats) included; bus transfer for evening theater performance included
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5
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