Emergency form - students of Faculty of Sports and Nutrition

We kindly ask you to complete this emergency form, so that we know how to contact you and/or your emergency contact person in the Netherlands in case of an emergency during your stay abroad. If details change during the semester, please complete the form again or contact the International office.

Please note: this form is meant for students who will do a minor or a study trip abroad. If you will do an internship, please complete the emergency form in Centuri.

For direct assistance in case of serious illness, personal accident or death in a foreign country, give direct notice to ACE assistance. Available 24/7 at telephone number: +31 (0) 10 289 3536.

Fields marked with * are mandatory

Personal details

Name

Student number

Study programme

Phone number

Phone number abroad

HvA email address

Private email address

Travel insurance company

Country of destination

City of destination

If you will visit more than one destination, please list city and country here

Day of departure

Day of return

Details related to your programme abroad

Name of the university or organisation/company you will be visiting

Name contact person

Phone number of contact person

Email address of contact person

Details of emergency contact person at home

Name of emergency contact person

Relation to you

Phone number of emergency contact person

Email address of emergency contact person