Participant Information Sheet

Personal Information

First Name:    Last Name:    Student ID:

Email:    Date of Birth:   Gender: (Select) Male Female

Permanent Address:

Tel:   Cell:   

Passport Number:   Date of Issue:   Date of Expiration:

Program Information

Host Program Name:   Start Date:   End Date:

Program Coordinator:   Tel:   Email:

Emergency Contact Information

1. Name:   Email:   Relationship:

Address:   

Cell:   Work:   Home:

2. Name:   Email:   Relationship:

Address:   

Cell:   Work:   Home:

Health Insurance Information

Primary Health Insurance Coverage:   Tel:

Website:   Policy Number:  

Mandatory Overseas Medical and Travel Insurance Coverage

All participants MUST provide proof of overseas medical and travel coverage for the term spent abroad by attaching a statement or letter of enrollment and/or card.

• Sponsored Program participants: You are automatically covered through ACE/Europassist while abroad.
• External Program participants: You must purchase Wells Fargo's plan if your host program or primary insurance does not include overseas medical coverage and 24 hour emergency assist services abroad.

Additional Information

I give the University of San Francisco's Center for Global Education permission to release my name, e-mail, and phone number while I am abroad or upon my return to students inquiring about my host study abroad program or country. 

 By checking this box, I hereby certify that all the information I provided on this Participant Information Sheet is true and correct.