Indiana State University
Travel Seminar
Information Release Form
Federal and State law prohibit the University from revealing certain information about its students. These laws would prevent the University from revealing information about your whereabouts, health, and safety while you are studying abroad. The following release would permit the University, if an emergency occurs, to notify specific persons about your whereabouts and condition. The second paragraph would authorize the University if an emergency occurs, to confirm or deny media reports, in order to prevent the dissemination of false information to shield you family and friends from press inquiries.
RELEASE
In the event of an emergency during my the time I am a participant in the ___________________________ Program, (for example if I should suffer any physical injury or other threat to my mental or physical well being), I hereby give permission to representatives of Indiana State University and this program to notify the following names persons of my whereabouts and/or my conditions.
Name:________________________________ Phone:________________________________
Name:________________________________ Phone:________________________________
Name:________________________________ Phone:________________________________
___________________________________ ________________________________
Signature Date
In the event of an emergency during the time I am a participant in the program, I hereby give permission to the representatives of Indiana State University and this program to provide the following information to the news media: to confirm or deny my status as a student of Indiana State University; to confirm or deny information concerning my whereabouts, health and safety.
___________________________________ ________________________________
Signature Date