Office of Global Initiatives
170 North St/Box 139
Dryden, NY 13053 USA
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.
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
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.
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Person(s) to notify in case of emergency, illness or accident:
Office of Global Initiatives
170 North St/Box 139
Dryden, NY 13053 USA
Student Declaration
I grant the State University of New York, its employers, agents and overseas partners permission to share
information concerning my health condition with program representatives, my family, insurance company
representatives and with any physician, psychologist or counselor who treated me during the past five years or is
now treating me. In situations where I am unable to give oral or written consent, I grant permission for
hospitalization and treatment recommend and carried out under the supervision of a qualified physician, including
administering anesthetics and performing necessary surgery at my own expense. I appoint the representative of
SUNY in the host country for the program to act on my behalf in authorizing necessary medical dental or surgical
care, hospitalization or medical evacuation for me should this be required. I certify that all responses made on this
form are true and accurate, and that I will notify the Administering Campus hereafter of any relevant changes in
my health that occur prior to the start of the program.
Student Signature Date
Please contact your health care provider to review your medical history and travel plans and have them sign below.
To the Student’s Physician
Please review the student’s medical history; make sure s/he is up-to-date on all vaccinations and discuss with
him/her the upcoming overseas study plans and sign below. A physical is not required by SUNY if you have
adequate information to advise the student. By signing below, you confirm to the best of your knowledge that
student is sufficiently physically fit and mentally stable to fully participate in all activities as described in the
course itinerary. This may include hiking, extensive walking on uneven surfaces, and other events. Accommodations
for disabilities should not be expected because the laws differ from the U.S. in this area. Travel in a group to another
country can be stressful and can provoke anxiety or depression and increase the likelihood that emotional problems
arise. Psychological stability for travel is essential. I have reviewed this student’s medical history and examination
with him/her, consulted with him/her about vaccinations and medications that may be required, and developed a
treatment plan for the student to manage his/her about condition during the overseas program, if needed (Attach
pages as necessary)
Signature of Provider Date REQUIRED: Stamp or seal of Provider’s practice with address and phone