Personal, Dietary, and Health Disclosure

Personal, Dietary, and Health Disclosure Form

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Name*
First Last
WC Email*
Gender (some of our providers require for housing/apartment purposes during the program)*
Diet and Health Disclosure Agreement
The diet and health disclosures are voluntary.

However, students are highly encouraged to provide OIP, Health Services, the Counseling Center, the Office of Student Accessibility Services, your program leaders and others the ability, where possible, to address any needs you may have during your program. Please understand that Whittier College CANNOT guarantee health, dietary or other accommodations while abroad. For food restrictions it is VITAL that participants maintain constant vigilance for themselves and that no guarantees regarding ingredients or food restrictions exist.
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Please answer the questions contained in this form as honestly and completely as possible. It is very important that all sections are completed fully and accurately, as this will assist health care providers should you require medical or counseling services during your study abroad program. The information provided will be treated confidentially.
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By accepting below I hereby give my permission for the OIP personnel to release my health disclosure form to Student Health, Counseling Center, the Office of Student Accessibility Services and, where applicable, to my Program Leader or others as deemed appropriate. I understand that this information will be shared only when necessary for my own or others' health and safety or to be sure arrangements can be made to meet my needs.
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In the event of illness, injury, or other medical emergency, I hereby grant Whittier College or any of its representatives, full authority to take any action deemed necessary to protect my mental or physical health and safety, at my expense, and to secure necessary treatment, including placing me under the care of a doctor or in a hospital or any place for medical examination or treatment, the administration of an anesthetic and surgery, and/or the administration of medication as may be prescribed by a doctor or if necessary for my safety or health. I agree that I may be returned to the United States at my expense. I agree that if Whittier College makes any payments on my behalf, I will reimburse the University regardless of whether I deem the treatment or services received to be medically necessary. I hereby assume all responsibility for all medical expenses that I may incur while abroad including the costs of my evacuation or return for medical or other reasons. .
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I authorize Whittier College to contact my Parents/Legal Guardian/Spouse about my physical or mental health while I am abroad if the University deems it advisable to do so. .
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I understand and agree that Whittier College is not obligated to secure or pay for medical treatment on my behalf and cannot guarantee the quality of any such treatment. I hereby release Whittier College and their respective trustees, officers, employees and agents from any and all liability, claims and causes of actions that might arise as a result of the exercise of their authority under this Agreement. .
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I certify that all responses made on this Health Disclosure Form are true and accurate, and that I will notify the University of any relevant changes in my health that occur prior to or during the term of the Program. I understand that this form is for information purposes only and in no way obligates the University or Program leader to take any responsibility for my health.
I have read and understand this document and agree that it will legally bind me and my estate, and I sign it voluntarily.
- I voluntarily agree to the terms of the Diet and Health Disclosure Agreement
Disclosure Choice
- None or none I wish to disclose now
- I would like to disclose a food/health or other condition

Prescriptions
Please list all current prescriptions and over the counter medications you take regularly as well as your plan for continuing them abroad. Some drugs available by prescription or over the counter in the US are illegal in other countries. Advanced preparation is important in having a successful education abroad experience
Allergies
Do you have any allergies (to medications, foods, insect bites, etc.)? If yes please list the allergy below, the severity of the allergy, and your plan for coping with any allergens. This question is important as exposure to allergens may be higher than what you experience locally.
Dietary Restrictions
Do you have any dietary restrictions (e.g. vegetarian, kosher, halal, restricted diet, etc.)? If yes please describe the plan you have in place for your time abroad. Your host country's diet may differ SIGNIFICATNLY from what you are used to so advanced research is important.
Mental Health Conditions
Are you currently being treated for or have ever been treated in the last 5 years for any mental health conditions (e.g. addiction, depression, anxiety, eating disorder, condition due to loss or grief, etc.)? If yes please describe below and provide your plan for managing the condition(s) while abroad if applicable.
Physical Health
Are you currently being treated for or have ever been treated in the last 5 years for any physical health condition, injury, or diseases (e.g. asthma, chronic conditions, cancer, cardiac conditions, epilepsy, migraines, etc.)? If yes please describe below and if applicable provide your plan for managing the condition(s) while abroad.
Disability Services
Do you believe you have a health condition or disability (e.g. learning disability, attention deficit disorder, diabetes, epilepsy, mobility restriction, visual or hearing impairment, mental health, or other) that may require reasonable accommodations to fully participate in a study abroad program? Yes or No. If yes, please contact Disability Services to see if there is a reasonable accommodation available.
- Yes
- No
Disability Services
If you picked "yes", you may wish to explain. You should still contact disability services if you are requesting reasonable accomodations.
Other
Is there any additional information that would be helpful for the program to be aware of during your study abroad experience? (If yes please explain below)