Medical Evacuation and Repatriation Insurance Form

(*) denotes required information.

Gettysburg College employees who are traveling abroad for college-related business are eligible for the medical evacuation and repatriation travel insurance coverage which is covered by the College. Immediate family members (spouse/partner, children 26 and under) traveling with employees on college related business may also purchase this same coverage for $1.33 per day or $233.00 per semester.

Students traveling abroad on research or short -term projects may also purchase this insurance for $1.33 per day or $233.00 per semester.

No personal travel will be covered under this insurance for employees or family members. If you are looking for insurance for personal travel, visit the Roam Right website .

If you require assistance to complete this form, please contact our office for advice (x6866,

* First Name:

* Last Name:

* Department


* Phone:

* Email:

* International Project

* Please give a short description of your international project.

* Please give precise departure and return information for insurance coverage (including dates and points of travel). If these dates differ for individual participants, please specify this.

* Please list all participants in this activity, including yourself. Please supply full name, sex, and date of birth for each participant. NOTE: If you have more than 10 participants please write "10+" below and send the list as an attachment to

NOTE: If you are the sole participant in this international activity, this is the only information required. If you are being accompanied by Gettysburg College students, please continue with the following questions.

Is it possible to register the names of group members and the official itinerary with the Embassy or Consulate?

In a medical emergency, how will the injured party be taken care of? Please include names and addresses of hospitals and routes for evacuation.

In the case of a natural disaster (e.g. earthquake) or a man-made disaster (e.g. bombs, coup d'etat), how will you report the status of the group to Gettysburg College?

If you become ill, get injured, or are otherwise unable to lead this group, who will step in to take your place? Please give full name and 24-hour contact information.

What information is given to participants and their families prior to departure regarding:
Contact information (including address and nearest telephone number for group)

Medical precautions such as required/suggested shots:

Who will be covering student insurance charges? (If department, please list account number. If student, checks should be payable to Gettysburg College and sent to campus box 421.)

NOTE: All students will need to complete the Agreement and Release form in order to participate in this international activity.