Medical Evacuation and Repatriation Insurance Form

(Please note your form session will expire after 15 minutes.)

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 will also be covered.

Students traveling abroad on college-related business are also eligible for coverage.

No personal travel will be covered under this insurance for employees, students, 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,

(Please include dates and points of travel for all participants.)

(If you have more than 10 participants please write "10+" 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?

(Please include names and addresses of hospitals and routes for evacuation.)

(e.g. earthquake, bombs, coup d’etat)

(Please give full name and 24-hour contact information.)

What information is given to participants and their families prior to departure regarding:

(Including address and nearest telephone number for group.)

(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.