Student Emergency Treatment Form - Wayne State University

Fields with asterisks (*) are required.

Applicant Information

Program Name *

Participant's First Name *

Participant's Last Name *

Phone Number *

Alternative Phone Number *

E-mail Address *

Program Information

Program Location (include all countries) *

Program Dates (include date ranges and year) *

Program Sponsor / Department *

*Most correspondence from our office will be via e-mail.
Please list one you check regularly.

Date of Birth *

Gender *

Male

Female

Citizenship *

Medical Information

This information is required to coordinate treatment in the event of a medical emergency. Answer “N/A” if not applicable. Attach another sheet if necessary.

Allergies

Medication Allergies *

Reaction *

Treatment, if exposed *

Food or Environmental Allergies *

Reaction *

Treatment, if exposed: *

Medications

Please list any medicines you are taking on a daily basis *

Additional Health Conditions

Do you have any health conditions other than those previously listed (such as surgeries, hospitalizations, injuries, chronic conditions, physical illness, psychological illness, emotional illness, mental illness, etc.) that may need special consideration before or during your experience or may affect your ability to participate in this program? *

Yes

If yes, you are advised to consult your health care provider. Please supply explanation below:

Conditions

How often do you have symptoms?

Plan for managing this condition while abroad

Disabilities

Are you registered with the Education Accessibility Services (EAS) for Persons with Disabilities? *

Yes (if yes, you are advised to discuss your plans to study abroad with your EAS specialist so you might increase your options abroad)

Do you have a disability that will require accommodations while abroad? *

Yes

If yes, please list special accommodation

Medical Records

The following must be completed. If you do not have a regular physician, indicate where your medical records are kept.

Physician Name *

Office Phone Number *

Emergency Phone Number

Address *

City *

State *

Zip Code *

Health and Emergency Agreement

I authorize the release of information contained in this Student Health/ Emergency Treatment Authorization Form for access and review by the director of WSU Study Abroad and Global Programs and the appropriate health care professionals at WSU. If further medical information is required, I understand that I will be contacted by a health care professional at WSU who will ask for a specific release for my personal health care professional(s), and/or clarify medical information with me directly. I understand that if this information is pertinent to my health and safety abroad, it may be discussed in a confidential manner with the director of WSU Study Abroad and Global Programs, the WSU program leader, host family, and the host institution’s resident director.

In the event that I need emergency medical care, hospitalization, or surgery while participating in the program, I authorize Wayne State University, through its representatives, to secure any necessary treatment. If coverage is not provided through the WSU Study Abroad and Global Programs insurance program, I understand that such treatment shall be solely at my expense, and I shall reimburse Wayne State University or its representatives for any expenses that they might incur on account of my condition or treatment. In the event of any emergency abroad, Wayne State University may notify my emergency contact listed on the Study Abroad application.

I certify that all responses made on this form are complete, true and accurate, and I will notify the Study Abroad and Global Programs Office immediately of changes in the state of my health. I understand that if I withhold information on this form I could be withdrawn from the program. If I am sent home for reasons related to withheld information, I will be responsible for all incurred costs. I understand that approval and participation in this study abroad program is contingent on receipt by the WSU Study Abroad and Global Programs Office of this completed signed form.

Signature *

Date *