Application - Forms

Post Acceptance: Student Information and Emergency Form

Please allow 5-10 minutes to complete the information form below. Have your passport, an electronic, passport-style, 2 x 2 photo, and your health insurance card available for quick and easy reference.
Please fill in all the required fields marked with * sign
Use the TAB key or your mouse to move between fields. Hitting the ENTER key will submit the form.

Photo

Note: All students are required to supply a photo. Passport-style photos are preferred.

Select Photo:

Personal Information

First Name*

Last Name*

Email*

Year of Study* (yyyy)

Date Of Birth* (mm/dd/yyyy)

Term of Study*

Academic Year

Fall

Spring

Summer

Location of Study*

Emergency Contact Information

Note: Emergency contact and at least one contact name for Parent/Guardian must be provided , together with at least one phone number for each provided contact

Father/
Guardian's Name*

Home Phone

Cell Phone

Day Phone

Mother/
Guardian's Name*

Home Phone

Cell Phone

Day Phone

Emergency Contact Name* (other than Parent/Guardian)

Home Phone

Cell Phone

Day Phone

Relationship to Student

Please rank your first, second, and third preference for whom to contact in case of emergency: (Click to select the option and move it pressing "Up" and "Down" buttons)

Passport Information

Note: If you do not have passport just check the box below, otherwise fill in all fields

I DO NOT have a passport

Citizenship

Passport Number

Date Passport Issued

Passport Expiration Date

Place Passport Issued

Place of Birth

Health and Accident Insurance Information

*I certify that I will be covered by the following policy during my participation in the SU Abroad program

Name of Insurance Company or Plan*

Policy/Group/Member Number

Policy is Valid Until*

Policy Holder Name*

Relationship to Student*

International Student I.D. Card

The International Student I.D.Card (ISIC) provides many benefits including some insurance. Please indicate a beneficiary (usually a parent/guardian) below:

Name of Beneficiary* (First, Middle, Last)

Address*

Address 2

City*

State*

Zip Code*

Phone*

Relationship to Applicant*

Health Information

Because a program of study abroad can be demanding and health care in other countries is different than in the United States, use this section to share withour program adminstrators information that you consider important to your health. The sharing of this information is voluntary.

I DO NOT HAVE health information to disclose

I DO HAVE health information to disclose (you will be directed to a new page)

Post-Acceptance Forms

Post Acceptance: Student Information and Emergency Form