Fillable Global Education STUDENT MEDICAL INFORMATION FORM (Spokane Community College)

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Global Education STUDENT MEDICAL INFORMATION FORM (Spokane Community College)

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CCS 5821 (Rev. 03/18)
Marketing and Public Relations
Global Education
STUDENT MEDICAL INFORMATION FORM
This is a report of your current medical status and conditions you may need assistance with while you are
abroad. Your information is confidential and will only be accessed by your Study Abroad support personnel
should you require medical or counseling support services during your participation in the program.
Name:
Are you generally in good physical condition? Yes No
If no, please explain:
Are you currently being treated for any medical condition? Yes No
If yes, please explain:
Are you diabetic? Yes No
Have you ever had epilepsy or another seizure disorder? Yes No
Do you have a heart condition? Yes No
If yes, please explain:
Do you have a history of having an eating disorder? Yes No
If yes, please explain status:
Have you been diagnosed with a medical condition in the past five years? Yes No
If yes, please explain:
Do you have any allergies? Yes No
If yes, please explain:
Do you take prescribed medications? Yes No
If yes, please explain the arrangements you have made for receiving your medications while abroad:
CCS 5821 (Rev. 03/18)
Marketing and Public Relations
Medical Insurance. All CCS study abroad students are required to have a U.S. medical insurance policy
while abroad. Please contact your U.S. medical insurance company to confirm your coverage and
procedures abroad. You will have in-country insurance provided by Colegia Delibes and must purchase
supplementary travel / study abroad insurance.
Please provide a copy of your medical insurance card and the information below:
Name on card:
Member number:
I certify that my responses on this form are true and accurate. I will notify the program administrator of any
relevant changes that occur prior to the program start date. I understand that the information on this form is
for information purposes only and does not imply responsibly on the part of Study Abroad staff for my health.
Student Signature:
Date:
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Global Education STUDENT MEDICAL INFORMATION FORM (Spokane Community College)

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Completed 8 October 2020

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