Please complete and return this form to:
Summer Study in Spain
WH 231
Eastern Connecticut State University
Willimantic, CT 06226
 

Student's name: _____________________________________________________________________________

1. In case of emergency, who in the United States should we notify?

Name:__________________________________________________________________________

Address:___________________________________________________________________________________

              ____________________________________________________________________________________

Phone: __________________________ Fax: ________________________ Email: ________________________
 

2. Do you have any medical problems we should be aware of?      Yes  /  No

    If yes, describe briefly:

_________________________________________________________________________________________

_________________________________________________________________________________________

______________________________________________________________________________

3. Are you taking any medication? Yes / No

   If yes, what? Be specific, and indicate any side effects

________________________________________________________________________________________

________________________________________________________________________________________

_____________________________________________________________________________

4. Do you have ECSU Student Health Insurance?    Yes  /  No

    If not, what form of health insurance do you have?

________________________________________________________________________________________