I understand that I am responsible for my own
health expenses while voluntarily participating in Foreign Travel for the
“Global Business Experience” course and that I am responsible for any
medical expenses that I may incur during that period of time, whether through
personal expenditures or through health insurance.
Name of Insurer
______________________________________________________________
Name Policy is
Listed Under ____________________________________________________
Policy Number
________________________________________________________________
Effective Dates of
Coverage _____________________________________________________
Is coverage abroad included? Yes _____________
No ______________
Signature
____________________________________________________________________
Name (print or type)
___________________________________________________________
Date
________________________________________________________________________