Office of Global Initiatives
170 North St/Box 139
Dryden, NY 13053 USA
Email: global@tompkinscortland.edu
www.tompkinscortland.edu/global
________________________________________________________________________________________________________
Your Name (Last, First, Middle) Program Location Abroad Primary SUNY Campus Student ID
To the Student: The information provided will remain confidential. Be aware that you will be responsible
for your own care, although Tompkins Cortland Community College and the organization hosting you
overseas will try to provide assistance. Please be honest with yourself and prepare accordingly. The
questions that follow will help guide you and Tompkins Cortland faculty and/or staff in preparing for you
stay abroad. Indicating that you have physical or mental health concerns may allow us to assist you in
determining if you are prepared to go and can receive appropriate treatment Disclosure is not meant to
be a barrier to travel but a way to have a conversation about how to make this trip a positive experience
for everyone.
1. Do you have or have you had any physical, psychological or emotional conditions (including
eating disorders), that might require treatment abroad, or that might be exacerbated by the
stress caused by changes in culture, climate, diet or exercise? If yes, explain below and plan
to see your health care provider to discuss you care.
Yes
No
2. Have you arranged to receive all the necessary immunizations and medications
recommend for visiting the program site by reviewing information that:
- May have been provided by Tompkins Cortland
- May have been provided by program site
- Is available on the US Center for Disease Control and Prevention website; and may be
available from the government of the countries you will enter?
3. Do you have any allergies, reactions to medications or dietary restrictions? If yes,
consider what you may need to manage you condition or restrictions. If needed, see your
health care provider for assistance in planning for your care. You may list any allergies or
dietary restrictions below so we can inform overseas providers. However, TC3 can only
inform and cannot ensure that you can be protected from exposure.
4. Are you currently taking or have you recently discontinued any medications you may
need while abroad? If yes, list medication names and purpose.
Please consider how you will have access to the medication you need and consult with your
physician to develop a plan for managing your condition while abroad. Depending on the
medication, Tomkins Cortland may request additional information
Yes
No
5. (Disclosure of disabilities is optional) Do you have a disability for which you are seeking
accommodations? If yes, provide a description of desired accommodations. Please be
aware that the Americans with Disabilities Act (ADA) do not apply outside the borders of
the United States. The Administering Campus will assist you, to the extent possible, to
obtain the accommodations necessary to enable you to participate in all aspects of the
overseas program.
Yes
No
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Person(s) to notify in case of emergency, illness or accident:
