This form is to help create awareness of any health issues that you should take into consideration before going abroad. This information will be used to guide us in assessing resources available at the site of your program. Please be thorough and complete with any comments and explanations. This information may be used in an emergency if you are unable to give the information yourself. Failure to disclose complete and accurate information may be grounds for dismissal from the study abroad program. Universities do not use this form when considering acceptance/denial to the study abroad program.
This information is secure and will only be used by those directly involved in the administration of the program. If you would prefer a paper copy of this form please contact Amy Nelson Green at email@example.com in the Office of International Education at Willamette.