Student Health/Emergency Treatment Authorization Student Health/Emergency Treatment Authorization Step 1 of 4 25% Which of the following will you be participating in?*RetreatImmersion experienceStudy abroadThe medical review of this form and admission into a program are independent of each other. The purpose of this form is to help John Carroll University provide appropriate assistance to you should the need arise during your program experience away from campus. It is important that we be aware of any medical problems (past or current), including mental health conditions, which might affect your ability to participate in a JCU program. This information will be kept confidential in accordance with the law. Any disclosure of such information will be made only to appropriate individuals, and handled with the highest level of discretion in order to protect student privacy. Relevant information will be shared with program staff, leaders, or appropriate professionals as it relates to your health and safety. Failure to disclose significant health issues may result in dismissal from the program. Health tests or immunizations may be required prior to departure in certain circumstances.Name* First Last Sex*FemaleMaleDate of birth* MM DD YYYY Email* Current address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Cell phone*Home phone*Name of retreat*Location of program*Location of immersion experience*Start Date* End Date* Medical Information Are you allergic to any medications?*YesNoMedications*Please list all medications that you have allergic reactions to. Please include the type of reaction and treatment should you be exposed to such a reaction.Do you have any food or environmental allergies or special diet considerations?*YesNoFood or environmental allergies, or special diet considerations*Please list all food and/or environmental allergies that you have. Please include the type of reaction and treatment should you be exposed to such a reaction. If you have special diet considerations, please let them here as well. If you have dietary restrictions or limitations, we strongly recommend you discuss them with your program leader.Are you taking any medications?*YesNoMedications*Please list any medicines you are taking on a daily, regular, or as needed basis and indicate how often and why each medicine is taken. (If studying abroad, see “Health Care” in the Study Abroad Pre-Departure Handbook for information regarding transportation and use of your medication abroad.) NOTE: Participants must bring an adequate supply of medications that are required on a daily or routine basis, in their original bottles. We suggest you bring a copy of all prescriptions. Are you registered with the Services for Students with Disabilities Office (SSD)? (If you think you may be eligible, contact SSD at (216) 397-4967)*YesNoIf yes, please discuss your plans with the SSD coordinator.Do you have a disability that will require accommodations while abroad?*YesNoIf yes, you must register with SSD and meet with the SSD coordinator. This must be done in a reasonable timeframe to allow for satisfactory evaluation of the requested accommodation and adequate time to implement the accommodation, if any. If you do not disclose your disability and/or request accommodation in a timely manner, JCU may not be able to assess and accommodate your needs.Do you have any additional health conditions other than those previously listed (such as surgeries, hospitalizations, significant injuries, chronic conditions, physical illness, psychological illness, emotional illness, mental illness, etc.) that may need special consideration before or during your experience or may affect your participation in this program?*YesNoIf yes, you are advised to consult with your health care provider.Please explain*Please give us a descriptions of your condition(s), how often you have symptoms and your plan for managing the condition(s) during the program. I authorize the release of information contained in this Student Health/Emergency Treatment Authorization form for access and review by appropriate health professionals in the JCU Student Health Center. I understand that if I have not turned in this form in a timely manner, there may be insufficient time for the JCU Student Health Center to review this information. If further medical information is required, I understand that I will be contacted by a health care professional in the JCU Student Health Center who will ask for a specific release to my treating health care professional(s), and/or clarify medical information with me directly. I understand that if this information is pertinent to my health and safety during the program, it may be discussed in a confidential manner with the JCU program leader(s), host family, and/or the host institution’s resident director (if applicable). In the event that I need emergency medical care, hospitalization, or surgery while participating in the program, I authorize John Carroll University, through its representatives, to secure any necessary treatment. In some cases, access to medical care may be more than 24 hours away and services may be limited. If coverage is not available through the JCU insurance provider, I understand that such treatment shall be solely at my expense, and I shall reimburse John Carroll University or its representatives for any expenses that they might incur on account of my condition or treatment. In the event of any emergency, John Carroll University may notify my emergency contacts. I certify that all responses made on this form are complete, true and accurate, and I understand that if there are any changes in my health status, I will complete and submit an updated Student Health/Emergency Treatment Authorization. I understand that if I withhold information on this form I could be withdrawn from the program. If I am sent home for reasons related to the withheld information, I will be responsible for all incurred costs. I understand that participation in this study abroad program is contingent on receipt by the JCU Student Health Center of this completed and signed form.Electronic Signature*I certify that all responses made on this form are complete, true and accurate, and I understand that if there are any changes in my health status, I will complete and submit an updated Student Health/Emergency Treatment Authorization. I understand that if I withhold information on this form I could be withdrawn from the program. If I am sent home for reasons related to the withheld information, I will be responsible for all incurred costs. I understand that participation in this program is contingent on receipt by the JCU Student Health Center of this completed and signed form.