Belmont Traveler Registration Form

Belmont Traveler Registration Form

This form should be completed by each individual traveling on an approved trip for Belmont University. Upon submission, you will automatically be given instructions for utilizing Belmont's Crisis24 Hotline.

General Information
Full Name:*

First NameLast Name
Email:*
Phone Number *
Please enter a valid phone number that you will have access to while traveling
BUID:*
Date of Birth*

MonthDayYear
Belmont role during travel:*

FacultyStaffUndergraduate StudentGraduate StudentBelmont AlumLumos ScholarOther
Your College/Department of employment or study*
Select the College or Department where you work/teach/study (Ex. someone employed by the College of Medicine traveling on a Belmont Mission trip would select College of Medicine in this box).
Please list your office/department of employment/study*
College/Department in charge of travel*
Select the College or Department authorizing/overseeing your travel. (ex. someone employed by the College of Medicine traveling on a Belmont Mission trip would select Belmont on Mission in this box).
Please list department in charge of travel*
Please list the person or office who has approved your travel:*
Please list name and email

Travel Information
Individual or Group Travel?*

Independent travelGroup travel involving studentsGroup travel involving additional Belmont staff/faculty/others
Countries and Cities of Travel:
Please use city, country format. Multiple entries sperated by "&"
Please enter the start and end dates of your Belmont-approved travel for work/school. Do not include any personal travel days. If you need supplemental international medical insurance, coverage will start and end on the dates entered below.
Departure Date (leave Belmont/home)*

MonthDayYear
First date of approved Belmont travel
Return Date (return to Belmont/home)*

MonthDayYear
Last date of approved Belmont travel
Total Number of Days for Approved Belmont Travel for Work/Study*
Please do not include any personal travel or vacation time

Locations of travel for the approved Belmont Work/Study*

Emergency Contact + Medical Information
Emergency Contact Name:*

First NameLast Name
Emergency Contact Relationship:*
Emergency Contact Number:*
Is the emergency contact traveling with you?*
Secondary Emergency Contact*
Name, Relationship, Mobile Number
Please list any medical information you wish to have on file in case of emergency*
This will not be reviewed by any Belmont Office. If you need medical guidance, please contact Health Services.

International Medical Insurance
Do you need international medical insurance for your travel?*
The cost is $4/day/person
Additional Information Required for Medical Insurance Enrollment

Please complete the following questions to be enrolled in Belmont's international medical insurance plan
Gender Recorded at Birth*
Home Mailing Address*

Street Address

Street Address Line 2

CityState

Zip Code
Date Range for International Medical Insurance Enrollment

Please confirm the start and end dates of your Belmont-approved travel for work/school. Do not include any personal travel days. Your international medical insurance coverage will start and end on the dates entered below.
Start Date*

MonthDayYear
First date of approved Belmont travel
End Date*

MonthDayYear
Last date of approved Belmont travel
Days of Medical Insurance Coverage
Please enter this value on the order form below to purchase your insurance coverage for the correct number of days.

Payments Required

Risk Management Support Fee(all students/employees must pay once per calendar year)

$75.00

Belmont Employee/Student International Medical Insuranceonly for approved work/travel days

$4.00 ENTER NUMBER OF DAYS

Subtotal

$0.00

Tax

$0.00

Total

$0.00

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Additional Information Required for Medical Insurance Enrollment