DCCCD Form 5: Medical Emergency Information

Completing this form is voluntary but strongly encouraged.

The following information is voluntary on your part, but can help travel leaders and college staff

in the case of an emergency. We encourage you to be as detailed as possible. This information

is strictly confidential and will not be shared with any individual or organization not directly

affiliated with the health and safety of project participants. Attach additional pages or

information if necessary.

If you do not wish to provide this information, go to the line titled “Decline to Answer,” sign and

date.

Note: This form contains sensitive, personal data and stored in digital, encrypted format on

the DCCCD network supported platform (NOT Dropbox, c: drive, jump drive, etc.) This

information will be available only to those with the proper clearance and in emergency only.

1. Please list any medical or mental health conditions you have in the event you require

treatment during your travel abroad.

2. Please list any medications that you are currently taking or expect to be taking during the

time of travel (include brand name and generic name if possible). Note: For prescription

medications, ask your pharmacist for a copy of the prescription in case you need to have

anything replaced during your trip. NOTE: Different countries may have legal restrictions on

medications available in the US. Consult your physician if you have questions or concerns.

3. Please list any allergies you have, including food and medication.

4. If you require eye glasses or contact lenses, please include a copy of your lens prescription

below with this form. Note: Lens replacement can be difficult or expensive in many

locations. Think ahead, and bring a back-up pair of lenses. Store them in separate luggage

from your other pair in case of loss or theft.

5. It is the policy of Dallas County Community College District to not discriminate on the basis of

disability in access to or participation in its projects or activities. DCCCD provides reasonable

accommodations to assist persons with disabilities, which affect their ability to access or

participate in its projects and/or activities. Although it is the intention of DCCCD to provide

accessible travel opportunities to all participants, legal mandates to provide reasonable

accommodations in the United States are not consistent worldwide.

6. If your religious beliefs or personal preferences preclude specific treatments, etc. please note

them here.

Persons who wish to request reasonable accommodations for this activity should contact the

Study Abroad Office for assistance. Requests should be made at least 8 weeks in advance for

domestic travel and 12 weeks in advance for international travel.

Decline to Answer:

Participant’s Printed Name

Signature:

Date: