CARM/D6625:GlobalFieldStudiesPracticuminConflictResolutionApplicationForm
Instructions:
1.PleasecompletethisformandtheapplicableReleaseofLiabilityformintheirentirety.
2.SubmittheoriginaldocumentstotheOfficeofInternationalAffairs,HorvitzAdministrationBuilding253(secondfloor).Keepacopyforyour
records.
3.Payyourdepositof$500.00bySunday,April15
th
,2018.ProgramfeesshouldbepaidbycreditcardusingtheNSUMarketplace(PREFERRED).
Thelinkisavailableonthecoursewebsite:www.nova.edu/internationalaffairs/travel‐study‐abroad/travel‐study/201850‐carmd6625‐ecuador‐
bastidas.Ifstudentsareunabletopaybycreditcard,checksandmoneyordersmaybeacceptedintheOfficeofInternationalAffairs,Horvitz
AdministrationBuilding253.ChecksmustbemadeouttoNovaSoutheasternUniversityandincludeyourfullname,N#,and“CARM/D6625”.
NAME____________________________________________________________GENDER_________________________
NSUID___________________________NSUEmail_________________________DATEOFBIRTH_________________
ADDRESS__________________________________________________________________________________________
PHONE_________________________________CELLPHONE_______________________________________________
EMERGENCYCONTACTNAME___________________________________________PHONE________________________
EMERGENCYCONTACTADDRESS_______________________________________________________________________
BACKUPEMERGENCYCONTACTNAME____________________________________PHONE_______________________
BACKUPEMERGENCYCONTACTADDRESS________________________________________________________________
Pleasereadandinitialeachofthefollowing:
___Ihavereadthecoursesyllabus.
___Ihavereadthepre‐tripinformation.
___IhavecompletedtheReleaseofLiabilityform,andwillsubmititwiththisapplication.
___Iamawarethatthetotalcostofthefieldtripis$1,500.00andthattheinitialpaymentof$500.00isadeposit.
___Iamawarethatafinalpaymentof$1,000.00isduenolaterthan5:00pmonTuesday,May1
st
,2018.
___Iamawarethatthisdepositandsubsequentpaymentsarenotrefundableiftheclassrunsasscheduled.However,iftheclassiscancelled,all
paymentsmadetotheUniversitywillberefunded.
___Iamawarethatthetotalcostforthefieldtripdoesnotinclude:
InternationalAirfare
TuitionandFeesforNSU
Mandatoryinternationalinsurancepurchasedatwww.internationalstudentinsurance.com/schools/nova‐southeastern‐university.php
Passportandimmigrationdocuments(ifrequired)
Personalexpenses
Ihavereviewedallinformationabouttravelcosts,deadlines,andexpectations.Iunderstandmyresponsibilitiesasastudentandtraveler.
__________________________________________ _________________
StudentSignatureDate
Ifstudentisunder18:
__________________________________________ _________________
Parent/GuardianSignature Date