The University of San Francisco: Center for Global Education

USF student in class





International Short Term Program 
Participant Information Form

Personal Information

First Name:    Last Name:    Student ID:

Major or Degree Program:   

Email:    Date of Birth:   Gender:

Permanent Address:

Tel:   Cell:

Passport Number:   Date of Issue:   Date of Expiration:


Country of Issue: 


Are you an International Student? 


Program Information
Study Abroad Program Name:   Start Date:   End Date:


Study Abroad Destination (city and country): 

Program Coordinator:   Tel:   Email:

Emergency Contact Information
1. 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 Coverage
All 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:

  • USF Sponsored Program participants: You are automatically covered through ACE/AXA while abroad. This coverage does not replace your primary health insurance and is supplemental coverage only.*
  • External Program participants (Not USF-Sponsored Participants): You must purchase a supplemental plan if your host program or primary insurance does not include overseas medical coverage and 24 hour emergency assist services abroad.
 Additional Information
Do you have any medical or psychological condition that as a participant in this program, the Program administrators should be aware? 
If yes, please describe the condition: 

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.