Student Program Registration Form

To register for a student program

• Complete the registration form below and pay your program deposit of USD$400, by credit card.
• Your deposit will only be processed if there is space open on the program of your choice.

Upon receiving your registration form and deposit

• We will confirm your place on the program, and send you a receipt and full pre-departure program information.
• If the program of your choice is full we will contact you immediately and offer you a place on the waiting list, or an alternative program.
• Before registering you can check if space is available on the program calendar which shows the current status of every trip.

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Program you are registering for * Select One Australia Summer Program Nepal & Tibet Semester Program New Zealand & Australia Semester Program New Zealand Summer Program Peru Summer Program Southeast Asia Semester Program Thailand Summer Program Vietnam Summer Program

Program date * Select Program First

 

Full name as in passport

First & Middle Names*

Last Name *

I like to be called

Date of Birth * Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month Jan Feb Mar Apr May Jun July Aug Sept Oct Nov Dec Year 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 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

Gender * MaleFemale

Mailing Address *

Primary Phone *

Alternate Phone

Email Address *

Alternate Email

 

Do you hold a current passport? * YesNo

Will you be travelling on a US passport? * YesNo

If no, what country's passport do you hold?

 

Are you a university student? * YesNo

University (if applicable)

Major (if applicable)

Year (if applicable) Gap year 1st year 2nd year 3rd year 4th year Graduate student

If not a student, what is your occupation?

Optional college credit is available to any participant on this program. Are you interested in earning credit on the program? * YesNo

 

Please outline previous travel experience *

Briefly explain why you would like to participate in this program *

If you will be coming on this program with a friend please enter their name

 

Primary parent or guardian you will be liaising with regarding this program:

First Name *

Last Name *

Evening Phone *

Email Address *

Relationship to you? * MotherFatherOther

If other, please specify

 

How did you discover this program? * Select One Personal referral Advertisement Internet search Other

 

Liability agreement: I acknowledge that I have read, understand and agree to the program booking conditions and liability release (click link to read/print)

Please enter your name and today's date to indicate your acceptance of booking conditions and liability release.

Name and date *

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