*J-1 Name:
*Email:

* DEPENDENT NUMBER: Select . . . 1 2 3 4 5
J-2 DEPENDENT PERSONAL INFORMATION:
1. *Family Name:
2. *First Name:
3. Middle Name:
4. Name as it appears on Passport:
5. Suffix:
6 . *Date of Birth (MM/DD/YYYY): Month . . . 01 02 03 04 05 06 07 08 09 10 11 12 Day . . . 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year . . . 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
7 . *Gender: Select . . . Male Female
8 . *Relationship: Select . . . Spouse Son Daughter Other-explain in next box Other:
9 . *City of Birth:
10. *Country of Birth:
11. *Country of Citizenship:
12. *Country of PERMANENT Residence:
13. Social Security Number:
14. Driver's License Number:
15. Driver's License Issue State:
16. Individual Taxpayer ID Number:

INSURANCE COVERAGE:
All J-1 holders and their dependents are required by Student and Exchange Visitor Program (SEVP) and Department of Homeland Security (DHS) regulations to have health insurance with specific minimum coverage requirements while in the United States. The minimum coverage requirements that your health insurance policy must have as specified by the SEVP include:

1. Medical benefits of at least $50,000 per accident or illness;
2. repatriation of remains in the amount of $7,500;
3. expenses associated with medical evacuation of the Exchange Visitor to his or her home country in the amount of $10,000; and
4. a deductible not to exceed $500 (22CFR 514.14)
An accompanying spouse or dependent of an Exchange Visitor is required to be covered by insurance in the same amounts [as the principal].

An Exchange Visitor who willfully fails to maintain the insurance coverage set forth above while a participant in an Exchange Visitor Program or who makes a material misrepresentation to the sponsor concerning such coverage shall be deemed to be in violation of these regulations and shall be subject to termination as an Exchange Visitor participant.

1. Name, address and phone number of organization or company providing insurance. If NOT covered under the Primary Exchange Visitor's insurance - please REMOVE the provided text in box below and type in appropriate information:
Dependent covered under Primary Exchange Visitor Insurance - with full and adequate coverage
* I certify that my dependent has or will have insurance coverage which meets the above requirements in effect for the period of time during which I am an Exchange Visitor participant in Skidmore College's Student and Exchange Visitor Program.

If you have questions, please contact:

Barbara Opitz
Designated School Official/SEVIS
Alternate Responsible Officer/Student & Exchange Visitor Program
Office of the Vice President for Academic Affairs
Skidmore College
815 North Broadway
Saratoga Springs, NY 12866
Ph: 518-580-8304