Passport, Medical, Travel & Credit Form

To complete this form, you need the following - please have this ready before you begin:

1) Your passport
2) Your next of kin contact details
3) Your personal medication details (if any)
4) Your vaccination details or intentions (not applicable for New Zealand or Australia trips)
5) Your travel insurance policy details
6) Your international flight itinerary
7) Your credit/class choices (if applicable)
8) A full face photo of you alone (as you would use to obtain a passport or drivers license), ready to attach and email
(if you do not have this, the form can be submitted without, but you need to email one to us as soon as possible)

For your safety and the wellbeing of the group, it is imperative you complete the following information honestly and accurately. All disclosures are confidential. Passport information is used to arrange your visas.

Pacific Discovery Booking Number If known. Usually PDY followed by 4 numbers.

Email * A copy of this form will be sent to you when you 'submit'

Passport Information

Please have your passport open in front of you when completing this.

Passport No. *

Given Names *

Surname *

Nationality *

Date of Birth *

Place of birth *

Gender * MaleFemale

Date of Issue *

Date of Expiry *

Authority *

Permanent Home Address

Street Address *

City *

State *

Zip/Post Code *

Country *

Emergency Contact Person

First Name *

Last Name *

Day Phone *

Evening Phone *

Street Address *

City *

State *

Zip/Post Code *

Country *

Medical Questionnaire

Please select 'yes' or 'no' to the following conditions.

Respiratory problems; asthma * Yes
No

Migraine headaches * Yes
No

Skin disorders * Yes
No

Muscular-skeletal problems * Yes
No

Diabetes * Yes
No

Claustrophobia; motion sickness * Yes
No

Neurological problems; seizures * Yes
No

Psychiatric conditions * Yes
No

Allergic reactions to medication * Yes
No

Dietary restrictions or preferences* eg. vegetarian Yes
No

Any chronic medical conditions * Yes
No

Any other allergies or illnesses * Yes
No

If yes to any of the above, please provide details. Please also list any other pertinent medical information that we should know.

Please detail any drugs or medication you currently take.

Have you had any first aid training? What level and when?

Height *

Weight *

What level of swimming ability do you have? *

Southeast Asia Semester Program only

Are you a certified scuba diver? Yes
No

All Programs (except those to New Zealand and Australia)

Please indicate vaccinations you have had or intend to have prior to the program.

Tetanus booster Yes
No

Hepatitis A Yes
No

Typhoid Yes
No

Anti-malarial medication

Other vaccinations

Travel Insurance Details

Name of your travel insurer *

Policy number *

24-hr international assistance telephone number (not a 1800 number) *

International Flight Itinerary

Program Start

City you are departing from *

Airline and flight number you are arriving on *

Date of flight arrival in program start city *

Time of flight arrival *

AMPM

Program End If your end of program plans are confirmed

Date of flight departure

Time of flight departure

AMPM

Optional Academic Credit

Are you enrolling for credit on the program?* Yes
No (If no, please go to next section)

What credit are you taking?

If other, please specify

How many credits are you taking?

Please list the course names

Do you need any assistance with credit registration? * Yes
No Note: Credit tuition payment is made directly to the college offering the credit, not Pacific Discovery, but we can assist with confirming your enrollment.

I verify that all the above information is correct, and am aware that if any of my passport information is incorrect, I am liable for extra fees associated with visa application/reissue. Additionally, I will inform the program coordinator, or my program leader if any of the above information changes at any time.
Please enter your name and today's date to verify the above information.

Name & Date *

Please attach a photo of yourself

Submit