Washington DC Career Exposure Visit Registration


DATE: October 24 & 25
COST: $100.00


Student Name:*


Phone Number While Traveling:*


Penn State Email Address:*



I. EMERGENCY CONTACT (required): Please give us a name of the person we should contact in the event of an emergency during the trip.

Name:*


Relationship to Student:*


Telephone Number:*


Email:*


Name of Primary Care Physician (If Applicable)


Primary Care Physician Phone Number (If Applicable)


Your health insurance carrier:



II. HEALTH/WELFARE INFORMATION (optional): to help ensure availability of appropriate services while on the trip, feel free to disclose with us the following information.

1) Are you currently receiving medical or psychological care of which you want us to be aware?
Yes
No

2) Is there anything in your medical or psychological history of which you want us to be aware? (for example, allergens, need for allergy shots, chronic conditions, etc.).
Yes
No

If the answer to any of the above questions is yes, please explain below or make an appointment with Grant Littke to discuss the issue.


* I have answered the above questions fully and truthfully.