Emergency Contact Information for CUSON Students Traveling Internationally

In order to complete the form, you will need to have your travel arrangements available, specifically your flight information.

Please complete as much of the as you are able. Thank you.

First Name*
Middle
Last Name*
Program*
UNI*
Email
Cell Phone Number
Start Date*
End Date*
Destination Time Difference From EST*	Ahead Behind
Hours Different from EST*
Organization Name*
Organization Street Address*
Organization City
Organization State
Organization Country*
Organization Zip/Postal Code*
Organization Phone (include int'l country and city codes)*
Organization Fax (include int'l country and city codes)*
Supervisor Name*
Supervisor Title*
Supervisor E-Mail*

Your Overseas Street Address*
Your Overseas City*
Your Overseas Country*
Your Overseas Postal Code
Your Overseas E-Mail*
Your Overseas Phone (include int'l country and city codes)*
If you do not know your phone number yet, please enter "I don't know" and return to this form and enter it when you do.
Your Overseas Fax (include int'l country and city codes)*
Passport Number*
Passport Country of Issue*

Emergency Contact Person #1 in the US*
Releationship to you*
Emergency Contact Phone*
Emergency Contact E-Mail*

Emergency Contact Person #2 in the US*
Releationship to you*
Emergency Contact Phone*
Emergency Contact E-Mail*

This itinerary is meant for basic information on where you will depart and where you will ultimately land. If your itinerary has more than one stop, please e-mail a copy to Judy Honig at jch3@mail.cumc.columbia.edu.
Outbound Itinerary Date*
Airline*
Flight #*
Departure Airport*
Arrival Airport*

Inbound Itinerary Date*
Airline*
Flight #*
Departure Airport*
Arrival Airport*
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