Fillable Honr2010g-flts-application - HONR 2010 G Travel Study Application Form

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Honr2010g-flts-application - HONR 2010 G Travel Study Application Form

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TravelStudyApplicationForm
HONR2010G:MedicalLondon:CultureandContext(Winter2019)
Instructions:
1. Pleasecompletethisapplicationforminitsentirety.Youwillneedtosubmittwocompleted
copiesofthisform.Pleasekeepathirdcompletedcopyforyourrecords.
2. SubmitonecopyofthisformtoJ.MatthewHoch,Ph.D.,associateprofessor,nolaterthan
WednesdayNovember1,2018by5:00pm.Dr.Hoch’smailboxislocatedintheMathScience
andTechnologySuiteonthethirdflooroftheParkerBuilding,nexttohisoffice,Parker357.
3. SubmitonecopyofthisformtotheHonorsCollegeOfficeoftheDeanbyWednesday,
November1,2017,by5:00p.m.TheOfficeoftheDeanislocatedonthefourthfloorofthe
CarlDeSantisBuilding(room4159).
4. TheinitialdepositmustbepaidbyMondayOctober29,2018by5:00p.m.Paymentismade
throughtheNSUMarketplace(onlinepayment:
https://www.nova.edu/internationalaffairs/travel‐study‐abroad/travel‐study/201930‐
honor2010g‐uk.html).Youmaymakepaymentsbycreditcardorelectroniccheckingaccount.
5. YoumustregisterforHONR2010GnolaterthanMonday,October29,2018by5:00p.m.
6. AnadditionalLiabilityWaiverformwillbeprovidedforyourreviewandisrequiredtobe
completedandsubmittedinatimelymanner.
NAME_____________________________________________________GENDER__________
NSUID________________NSUEMAIL__________________DATEOFBIRTH_____________
ADDRESS____________________________________________________________________
PHONE______________________________CELLPHONE____________________________
EMERGENCYCONTACTNAME_______________________PHONE_____________________
EMERGENCYCONTACTRELATIONSHIPTOSTUDENT__________________________________
EMERGENCYCONTACTADDRESS_________________________________________________
BACKUPEMERGENCYCONTACTNAME___________________PHONE__________________
BACKUPEMERGENCYCONTACTADDRESS___________________________________________

BACKUPEMERGENCYCONTACTRELATIONSHIPTOSTUDENT____________________________
Pleasereadandinitialeachofthefollowing:
___Ihavereadthepreliminarycoursesyllabus.
___IwillcompletetheReleaseofLiabilityform.
___Iamawarethatthedirectinstitutionalcostofthefieldtripis$2500andthatapaymentof
$1,000isrequiredbyMondayOct.292018asadeposittoholdmyspaceintheclass.
___Iamawarethatafinalpaymentof$1500isduebyDecember1,2018,5:00p.m.
___IunderstandthatallpaymentsaremadethroughtheNSUMarketplace.
___Iamawarethatindirectcostsaretheresponsibilityofthestudent(includingmealsandother
on‐siteexpenses)andareestimatedtobe$100perday.
___Iamawarethatthisdepositandsubsequentpaymentsarenonrefundableiftheclassrunsas
scheduled.However,iftheclassiscancelled,allpaymentsmadetotheUniversitywillbe
refunded.
___IamamemberoftheFarquharHonorsCollege.
___Iamawarethattheinstitutionalcostforthefieldtripdoesnotinclude:
tuitionorotherNSUfeesrelatedtothiscourse
snacks,lunches,dinners
admissionfeesthatarenotpartoftheofficial,requireditinerary
OysterCard(feecardforLondon’sMetrotravelsystem)
travelinsurance
incidentals,gratuities
___Iamawarethatacopyofmypassport(whichmustbevalidforatleast6monthsfollowingtheendof
thetrip)isduetotheOfficeofInternationalAffairsbyJanuary8,2019.
___IamawarethatifIhaveanon‐U.S.passport,itismyresponsibilitytocontacttheOfficeof
InternationalAffairsandsecurealladditionalimmigrationdocumentsindependently.
___Iamawareofthefollowing:Travelstudytripsoftenrequirestrenuousactivitythatmaybe
difficultforsomestudents.Inmanydestinations,specialaccommodationsarenotavailable.Ifyou
mayrequirespecialaccommodationstoparticipateinatravelstudytrip,pleasespeakwiththe
respectivefacultymembertodeterminewhetherornotyoushouldenrollinthisclass.
Ihavereviewedallinformationabouttravelcosts,deadlines,andexpectations.Iunderstandmy
responsibilitiesasastudentandtraveler.
________________________________________ _________________
StudentSignature Date
Ifstudentisunder18:
__________________________________________ _________________
Parent/GuardianSignature Date
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Honr2010g-flts-application - HONR 2010 G Travel Study Application Form

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Completed 17 November 2019

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