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Which of the following will you be participating in?

The medical review of this form and admission into a program are independent of each other. The purpose of this form is to help John Carroll University provide appropriate assistance to you should the need arise during your program experience away from campus.

It is important that we be aware of any medical problems (past or current), including mental health conditions, which might affect your ability to participate in a JCU program. This information will be kept confidential in accordance with the law. Any disclosure of such information will be made only to appropriate individuals, and handled with the highest level of discretion in order to protect student privacy. Relevant information will be shared with program staff, leaders, or appropriate professionals as it relates to your health and safety. Failure to disclose significant health issues may result in dismissal from the program.

Health tests or immunizations may be required prior to departure in certain circumstances.

Name

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Current address
Phone format: (###) ###-####
Phone format: (###) ###-####