International Internship Emergency Information 2008

International Internship Emergency Information 2008

This form provides you and our office valuable information in case of emergency. Please fill out the form completely and print at least two copies for your record. We recommend you give a copy of this information, along with a photo copy of your passport and visa, to both your internship supervisor and program coordinator (if applicable).

Please note: Required fields are followed by an asterisk (*).

	Applicant Information
First Name:	*
Middle Initial:
Last Name:	*
	Applicant Citizenship Information
Country of Citizenship:	*
Country of Citizenship (if dual):
	Contact Information
Permanent address:	*
Telephone:	*
	Summer Contact Information: While living abroad I may be reached at the following address and telephone number(s):
Address:	*
Phone Number:	*
	Parent/Guardian Information:
	Parent/Guardian #1 Information:
Name:	*
Address including street, city, state, zip code and country:	*
Home phone number:	*
Work phone number:	*
Fax Number:	*
Email Address:	*

	Parent/Guardian #2 Information:
Name:
Address including street, city, state, zip code and country:
Home phone number:
Work phone number:
Fax Number:
Email Address:

	In addition, if I have a medical or security emergency, please call the following, in order:
First to call name:	*
First to call relationship:	*
Address including street, city, state, zip code and country:	*
Home phone number:	*
Work phone number:	*
Fax Number:	*
Email Address:	*
Second to call name:
Second to call relationship:
Address including street, city, state, zip code and country:
Home phone number:
Work phone number:
Fax Number:
Email Address:

	Summer Supervisor Contact Information: If you are going through an international program that is based in the United States, list the names of BOTH* the on-site coordinator and the person who oversees the program from the United States.*

	Supervisor #1 Information:
Name:	*
Organization:	*
Address including street, city, state, zip code and country:	*
Work number:	*
Fax number:	*
Email:	*
	Supervisor #2 Information:
Name:
Organization:
Address including street, city, state, zip code and country:
Work number:
Fax number:
Email:
	List contact information for the following places:
United States Embassy:	*
The closest hospital:	*
The closest women's center/rape crisis center:	*
The closest university:	*
I have the following allergies/medical concerns:

This form is not complete until you have brought a photocopy of your passport and visa to Beth Robichaud in the CWS.

List the following information on your printed copy of this form.
Note: A short amount of time today will save a big headache later. Insurance Information (health, liability, evacuation, etc.)
Travelers Check Numbers and the number to call if they are lost or stolen
Credit Card/Bank Card phone numbers to call if they are lost or stolen
Do not write your credit card or PIN numbers on this sheet

For more information contact Beth Robichaud, CWS, erobicha@wellesley.edu, ext. 2254.