Medical Information and Liability

Please carefully read and complete the Study Abroad Student Medical Information and Liability Waiver below. All fields are required.

Please email questions to International Programs and Services: ips@mtu.edu.


Participant Information




Student Medical Information and Liability Waiver

Michigan Technological University international programs and activities may involve a variety of activities in outdoor settings. These may include rigorous and remote physical activities.

There is a risk associated with international activities and programs, which must be assumed by each student. He or she may incur injury, as there are certain risks inherent in rigorous and remote activities.

The information gathered on this medical form is intended to help inform the program director and assistants of any pre-existing medical conditions, and to help determine if consultation with your physician is recommended prior to your taking/joining this course or program. If you have a pre-existing condition, participation in some of the activities may not be recommended. This information will be kept in strict confidence by Michigan Technological University and shared only with your permission.

Insurance

Do you have health/accident insurance?

  Are you generally in good physical condition? (If no, please explain below.)
 

   Have you ever been treated or are you currently being treated for any psychological, emotional, alcohol or substance abuse problems? (If yes, please explain below.)
 

  Do you have allergies to drugs or foods? (If yes, please explain below.)

  Are you taking any medications? (If yes, please explain below.) Certain prescription medications may not be available or allowed in some countries. Know before you go so you can plan for this.
 

  Have you had any major injuries, diseases or ailments in the past five years? (If yes, please explain below.) Certain prescription medications may not be available or allowed in some countries. Research and plan ahead.
 

  Is there any additional information (concerning medical conditions or mental, learning, or physical disabilities) that would require accommodation or be helpful for the program to be aware of during your study abroad experience? (If yes, please explain below.)