Participant Health & Emergency Information

The information that you provide in this form will be retained on file by Center for Learning in Action staff for the duration of your trip in case of emergency or other incidents. Trip organizers will be given a roster of their trip participants with this information as well, to keep readily available during the trip for the same purposes.

Please contact the Center for Learning in Action ([email protected]) if you have any questions or concerns about this form or the information requested.
  • Your Information

  • Please include your full name (first, middle, last and suffix, if applicable) exactly as it appears on your passport or government-issued photo ID.
  • Please indicate your sex as it appears on your current passport or government-issued ID.
  • Date Format: MM slash DD slash YYYY
  • This is required in case your trip organizers need to find you when the ground transportation is departing from campus.
  • Emergency Contact Information

  • Trip Selection

  • Carbon Footprint Calculation

    As a continuation of Williams' "Confronting Climate Change" initiative, we are asking all Break Out Trip participants to calculate their individual carbon footprint, and for each trip to consider possibilities for reducing or offsetting this footprint.
  • Please check all that apply.
  • Please indicate the round-trip mileage for your primary mode of transportation.
  • Use TerraPass to calculate. Click "Individual Calculator," then choose your primary vehicle type, destination, etc. Your emissions will be calculated in "lbs of CO2e") on the bottom right hand side.
  • Health Information

  • If you have any particular health issues or concerns of which you feel we should be aware, please describe them here.
  • Please list any medications you take regularly of which you would like us to be aware, particularly any prescriptions which may need to be replaced if lost while traveling.
  • Please list any serious allergies which may require use of an EpiPen or other emergency attention.
  • Agreement

    By clicking "Submit," you certify that the information you have provided on this form is accurate, true and complete to the best of your knowledge.
  • Date Format: MM slash DD slash YYYY