Information Sheet
International Business Strategy and Culture
Name (exactly as appears in official documents)
E-mail
Cell phone
Home phone
Address
Birthdate (Month, date, year)
Gender:
M/F
Academic Adviser
Year in School
U.S. Citizen Y/N
Passport number (if
available)
Emergency contact name
Cell phone
E-mail
Work phone
Major
Passport expiration
Relationship to you
Home phone
Please answer the following questions in the space provided. Answers may be
handwritten or typed.
1.
Why do you want to participate in this MBA study tour? What do you hope to
learn and experience through this visit to Brazil?
.
2. Have you ever traveled abroad? If yes, when, where, why, and for how long?
3. How did you first learn about this program?
Behavior code
While abroad, I accept the responsibility of acting as a representative of both my
country and Mount Mercy University. I will respect the laws of my host country, and
maintain a high standard of conduct at all time. I understand that drug use, heavy
drinking, or any behavior dangerous to myself or disruptive to the group will result in my
expulsion from the program and my departure to the United States at my own expense.
I will attend all classes, meetings, visits, and cultural excursions, and will be on time for
group departures. If I miss a departure, I accept the responsibility to make my own way
to the appointed place. I understand that I am not permitted to rent any cars,
motorcycles or other power vehicles.
Signed:_________________________________ Date:_____________________________________
Health Information Form
Study abroad programs expose students to new environments and new activities. Long
distance travel can create physical and mental stress that can trigger existing conditions.
The information on this medical form will inform Mount Mercy staff of any pre-existing
health conditions and help determine if consultation with your medical provider is
recommended or required prior to travel. Failure to disclose relevant information can
lead to a number of consequences, including difficulties with insurance, entry into a
foreign country, and exclusion from the program.
Health Information
1. Do you have any allergies? If so, what are the symptoms? How do you treat them?
2. Do you have any pre-existing health conditions? Have you been treated by a health
care professional, other than for a routine check-up, at any point in the past five years?
(This should include both physical and mental health conditions.)
Please describe.
3. Are you taking any prescription medicine? If so, what?
4. Do you have any mobility issues or require any special accommodations? Travel
abroad may involve climbing stairs, walking long distances, getting on and off public
transportation.
5. Do you have any special dietary needs? (Vegetarian, diabetic, religious) Please
describe.
6. Health insurance company
7. ID No
8. Group No
9. Name, address and phone number of personal physician
Please attach a copy of your health insurance card.
By signing this release, you acknowledge that the information is complete and authorize
the sharing of this information with the program director and other Mount Mercy
personnel as necessary and appropriate.
Signature___________________________
Name (printed)_______________________
Date__________________________