Participant Travel Data Form

Your Information

Name*

Please include your full name (first, middle, last and suffix, if applicable) exactly as it appears on your passport or government-issued photo ID.

Sex*

Please indicate your sex as it appears on your current passport or government-issued ID.

Female
Male

Preferred Pronouns

Date of Birth*

Home Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Passenger Cell or Trip Contact Phone*

Passenger Email*

Enter Email Confirm Email

Dorm Room or Residential Address at Williams*

This is required in case your trip organizers need to find you when the ground transportation is departing from campus.

Emergency Contact Information

Name*

First Last

Relationship*

Phone*

Email*

Enter Email Confirm Email

Trip Selection

In which 2019 Break Out Trip are you participating?*

Addressing Gender Inequality in Education: India
Chaplains’ Interfaith Service Team: Tuscaloosa
Global Medical Training: Peru
The Real Face of Mexico (Nogales)
Solidarity Economies: Cooperation Jackson
Teaching English in China
TEED Ghana
Williams in Mexico (Veracruz)

Seating Preference*

We cannot guarantee availability of seating preferences.

Aisle
Center
Window
No Preference

Preferred Return Flight Destination*

Please include the city, state and 3-letter airport abbreviation if known, e.g., "Chicago, IL - ORD." The default itinerary will be a round trip returning to the original departure airport (most likely Albany, Hartford, Boston, New York or Newark, depending on the trip). In some cases, return flights to your preferred destination may be possible, and requests will be handled on a case-by-case basis for each trip.

Travel Origin*

Please indicate the origin from which you will be traveling to India. Please include the city, state and 3-letter airport abbreviation if known, e.g., "Chicago, IL - ORD," or whether you will be traveling from campus, your home location, or elsewhere.

Note: The India trip will begin partway through the first week of Spring Break, on Thursday, March 21st. Students may be responsible for getting themselves to the primary international departure airport (most likely JFK, Newark or Boston) so that the group can travel to/from India together on the same round trip itinerary.

Required Information for International Travel

Passport Issuing Country*

Country of Residence*

Passport Number*

Passport Expiration Date*

Carbon Footprint Calculation

As a continuation of Williams' "Confronting Climate Change" initiative, we are asking all Break Out Trip participants to calculate their individual carbon footprint, and for each trip to consider possibilities for reducing or offsetting this footprint.

Mode(s) of Transport to Service Site*

Please check all that apply.

Total Round-Trip Miles to/from Service Site*

Please indicate the round-trip mileage for your primary mode of transportation.

What is the carbon footprint of your primary mode of travel to and from your service site (in lbs of CO2e)?*

Use TerraPass to calculate. Click "Individual Calculator," then choose your primary vehicle type, destination, etc. Your emissions will be calculated in "lbs of CO2e") on the bottom right hand side.

Health Information

Health Insurance Company*

Policy #*

Subscriber Name*

Insurance Company Phone Number*

Health Issues or Concerns

If you have any particular health issues or concerns of which you feel we should be aware, please describe them here.

Medications

Please list any medications you take regularly of which you would like us to be aware, particularly any prescriptions which may need to be replaced if lost while traveling.

Food or Other Allergies

Please list any serious allergies which may require use of an EpiPen or other emergency attention.

Dietary Restrictions

Agreement

By clicking "Submit," you certify that the information you have provided on this form is accurate, true and complete to the best of your knowledge.

Signature*

First Last

Date*

About

Academics

Admission & Aid

Life at Williams

Participant Travel Data Form

Your Information

Emergency Contact Information

Trip Selection

Required Information for International Travel

Carbon Footprint Calculation

Health Information

Agreement

About

Academics

Admission & Aid

Life at Williams

Participant Travel Data Form

Your Information

Emergency Contact Information

Trip Selection

Required Information for International Travel

Carbon Footprint Calculation

Health Information

Agreement

Social Links