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Student Health Service

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Immunization Requirements

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Food Allergies

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Pharmacy

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Forms

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International Travel Clinic

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Women's Health Clinic

* Insurance Information

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---The "Morning After Pill"

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Suggestions?


International Travel Itinerary Form

Students who are traveling to international destinations should complete the following questionaire to assist the Student Health Service in determining if vaccines and medications are needed to prevent travel related illnesses. The Student Health Service will review this information and contact you about scheduling an appointment if vaccines and medications are needed for your particular itinerary. Simply fill in the blank or click onto the correct response for the questions below and SUBMIT.

Date:

Name:

Phone:

SS#:

or Student I.D. #:

E-mail:

Departure Date:

Return Date:

Destination(s):

Sponsoring Group:

Director's Name:

Director's Phone #:

Previous international travel destinations (for individual travelers only):

Planned Travel Itinerary (list destination and length of stay, in order of travel):

Destination (city, country)

Length of stay

Purpose of Travel (check all that apply):

Business

Missionary

Foreign study

Vacation

Field Work

Camping/hiking

Teaching

Cruise

Volunteering

Accommodations:

Hotel

Rented home

Resort

Camp

Youth Hostel

University Housing

Will you be staying and eating with a host family?

Yes

No


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