International Short Term Program Participant Information Form
First Name: Last Name: Student ID:
Major or Degree Program:
Email: Date of Birth: Gender:
Passport Number: Date of Issue: Date of Expiration:
Are you an International Student?
Program InformationStudy Abroad Program Name: Start Date: End Date:
Study Abroad Destination (city and country):
Program Coordinator: Tel: Email: Emergency Contact Information1. Name: Email: Relationship:
Cell: Work: Home:
2. Name: Email: Relationship:
Cell: Work: Home: Health Insurance Information (Mandatory)Primary Health Insurance Coverage: Tel:
Insurance Company Address:
Policy Number: Subscriber ID Number:
Mandatory Overseas Medical and Travel Insurance CoverageAll participants MUST provide proof of overseas medical and travel coverage for the term spent abroad (a statement or letter of enrollment and/or copy of both sides of insurance card) by email attachment to: firstname.lastname@example.org
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 study abroad program or host country.
By checking this box, I hereby certify that all the information I provided on this Participant Information Form is true and correct.
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2130 Fulton St.
San Francisco, CA 94117-1045
Hours: M-F, 9:00 a.m. – 5 p.m.
Telephone: (415) 422-6848Fax: (415) 422-5908Email: email@example.com Map & Location