Graduate Research & Independent Programs

Name: ______________________________ SSN: _________________________

U.S. Address: __________________________________________________

U.S. Phone Number: _____________________________________________

Department (Major): _____________________________________________

Advisor: _______________________________________________________

Research Topic: _________________________________________________

Country(ies): ____________________________________________________

Departure Date: ___________________________________________________

Return Date: ______________________________________________________

Your contact Address & Phone number while you are abroad: ___________________

Emergency Contact while you are abroad:

Name:_______________________________________ Phone #: _________________

Address: ______________________________________________________________

Relationship to you: _____________________________________________________

If you will have someone acting as your power-of-attorney while you are abroad, please provide their contact information:

Name:_______________________________________ Phone #: _________________

Address: ______________________________________________________________

Relationship to you: _____________________________________________________

You will need to provide the Office of International Programs (OIP) with the above information at least 30 days prior to departure. In addition, you will need to submit:

Agreement & Release Form (from OIP)

Health Questionnaire (from OIP)

Proof of Medical Insurance

Copy of Passport

Copy of Flight Itinerary