Students who are traveling to international destinations should complete the following questionnaire to assist Deacon Health in determining if vaccines and medications are needed to prevent travel-related illnesses. Deacon Health will review this information and contact you about scheduling an appointment if vaccines and medications are needed for your particular itinerary. Simply fill in the blank or click on the correct response for the questions below and SUBMIT.

Please email if you have any questions.

International Travel Itinerary Form

"*" indicates required fields

Today's Date*
Date of Birth*
Departure Date*
Return Date*
Director's Name
Purpose of Travel (check all that apply)
Will you be staying and eating with a host family?