AJY Emergency Contact Form

Personal Information

First Name: *

Last Name: *

Email Address: *

Which program will you be participating in: *

Fall

Spring

Summer

Family Information

Father's name: *

Address: *

City: *

State: *

Zip/Postal Code: *

Primary Phone: *

Secondary Phone:

Email Address:

Mother's name: *

Address: *

City: *

State: *

Zip/Postal Code: *

Primary Phone: *

Secondary Phone:

Email Address:

Emergency Contact Information

Name: *

Relationship: *

Address: *

City: *

State: *

Zip/Postal Code: *

Primary Phone: *

Secondary Phone: *

Email Address: *

Home School Contact Information

Name of study abroad advisor or equivalent:

Advisors Phone:

Email Address:

College/University:

School address:

City:

State:

Zip/Postal Code:

Word verification: * Type the characters you see in this picture.

(verify using audio)

Type the characters you see in the picture above; if you can't read them, submit the form and a new image will be generated. Not case sensitive.

Contact Information

The American Junior Year at Heidelberg University
Heidelberg University
310 E. Market St.
Tiffin, OH 44883-2462

telephone: (419) 448-2062 or 1-800-925-9250
fax: (419) 448-2217
Email: ajy@heidelberg.edu

Main menu

AJY Emergency Contact Form