Health & Emergency Contact Information for Off-Campus Program Travel

Congratulations on your decision to travel on an off-campus program with CSB/SJU.  The Office for Education Abroad, CSB & SJU Campus Ministry Offices, the Institute for Women's Leadership, and all of the academic departments are excited to support you in your adventure.

In order to assure that we have the necessary information in case of an emergency, we ask that you please complete the following medical, health insurance and emergency contact information.  This information will only be shared with the office supporting your program and your program director.

You will also need to sign the Short-Term, Off Campus, Program Waiver and Release Form.  (http://www.csbsju.edu/oea/Short-TermWaiver.htm) Please note: You only need to print and sign the one cover page.  Be sure to read each of the attached documents. 

Please submit this Waiver and Release Form to your program director. 

Your Demographic Information



















Date of Birth
   
   
   

Do you have a valid passport?

Passport Issue Date
   
   
   
Passport Expiration Date