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Left Arrow Back > Home > Foreign Travel Insurance Registration Form
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Foreign Travel Insurance Registration Form
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I. Requestor
* First Name:
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* Last Name:
* Department | College:
Course # (if applicable):
* Phone Number:
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* Purpose of Trip:
* Destination | Country #1:
Destination | Country #2:
Destination | Country #3:
* Departure Date:
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* Return Date:
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II. Person in charge on trip
* First Name:
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* Last Name:
* Department | College:
* Phone Number:
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Phone Number Alt:
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FAX Number:
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* Email Address:
III. Participant Information
Number of Participants:
Students: spacer Employees: spacer Chaperones:
(Not Employees)		 spacer Others:*
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* If "Others" are on trip, please explain:
IV. Emergency Contact Information
Necessary information for Policy Activation.
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* Participant List:
(Please copy & paste participants names & phone numbers into window above)
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* Trip Itinerary:
(Please copy & paste full daily trip itinerary into window above)
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California State University, Stanislaus
One University Circle
Turlock, CA 95382