Your name:
Your email:
Program you are applying for: Please Select: Intersession Spring Semester in the Andes Ohio Spring Quarter Augustana Summer Spanish Program Anthropology in the Andes Summer TEFL Fall Semester in the Andes Blair Academy Burr-Burton Academy Full Immersion Spanish Program Spanish Immersion Volunteer Program Medical Spanish in Ecuador Program Internship

PARENT/GUARDIAN AND EMERGENCY CONTACT

Person to contact in case of emergency:

Name:
Relationship to applicant:
Address

Phone:
E-mail:

If under age 21, list the name and address of your parent or guardian (you do not need to fill in this information if you listed a parent/guardian as your emergency contact):

Name:
Address:

Phone:
E-mail:

Health Information:

(Please note: any information provided here is for emergency purposes only, and will be kept strictly confidential)

Are you taking any medications? yes no
If yes, what medication and for what reason?:

Do you have any serious allergies to foods or other environmental factors (seafood, peanuts, etc)? yes no
If yes, please explain to what and the typical reaction:

Are you allergic to any medications (penicillin, ibuprofen, etc.)? yes no
If yes, please explain:

Do you have any current or previous medical conditions that might affect your participation in one of our programs? yes no
If yes, please explain:

Do you have health insurance that will cover you in Ecuador, or will you be purchasing such insurance before traveling? yes no
Please provide any details below:

Is there anything you think we should know?: