Student Declaration
I grant the State University of New York, its employees, 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
recommended 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's Signature Date
Parent/Guardian’s Signature (required if student is under 18 years of age) Date
If you answered yes to 1, or 4, or no to 2 please make an appointment with your health care
provider to review your medical history and travel plans and have him/her sign below.
To the Treating Clinician: Please review the student’s medical history, discuss with him/her the upcoming
overseas study plans and sign below. A physical exam is not required by SUNY if you have adequate
information to advise the student.
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
condition during the overseas program, if needed. (Attach pages as necessary.)
Signature of Provider Printed Name of Provider
Address and Phone Number of Provider
