Havana Passage: A Photographic Workshop - January 2017
Registration
Program Name:
Havana Passage: A Photographic Workshop
Start/End Dates:
January 11 - 16, 2017 (tentative)
Today’s Date:
Name1:
1
Your name exactly how it appears on your passport.
Email:
Phone (preferred):
Alternate Phone:
Gender:
DOB:
Street Address:
City:
State:
Zip:
Roommate(s):
Registration accepted on a first-come, first-served basis. Space is limited. All non-credit/debit card payments are to
made payable to WKU Study Away.
See Program Detail sheet (Green Sheet) for details:
http://www.wku.edu/americantraveler/programs/cubaphoto2017.php
Items Subject to Change
The trip is based on a minimum number of people to participate. Program activities may be revised to accommodate a
smaller or larger number of participants if necessary.
American Traveler are a short-term, noncredit programs offered by WKU’s Office of Study Away, designed to provide intense, unique
travel experience to fascinating locations. These lifelong learning opportunities are developed and led by experts and designed to give
participants a one-of-a-kind experience.
WKU’s Office of Study Away administers Study Away courses, Faculty-Led Study Abroad courses, and the Cooperative Center for
Study Abroad program. Study Away is a unit of the Division of Extended Learning and Outreach.
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Havana Passage: A Photographic Workshop - January 2017
Registration
EMERGENCY CONTACT INFORMATION
Name:
800# (if WKU)
Phone (preferred):
Email:
Address:
City:
State:
ZIP:
PARTICIPANT PASSPORT INFORMATION
Passport Number:
Issue Date:
Expire Date:
Place of Issue:
Citizenship:
Base Package Price: $4,399 – $4,699
** Single room supplement add $699.
Range due to number of participants, changes in flight and lodging availability due to US-Cuban relations.
Double (per person)
Single
Occupancy
July 1, 2016
$500
$500
September 1, 2016
$1,174
$1,349
October 1, 2016
$2,349
$2,699
November 1, 2016
$376 - 676
$550 - $850
$4,399 – 4,699
$5,098 - $5,398
PAYMENT (all non-refundable)
Priority Registration and Deposit:
First Payment (25%)
Second Payment (50%)
Final Payment (estimate):
Payment Amount:
Payment Method:
Check
(#___________)
Discover
MasterCard
Visa
(cash not accepted)
Name on card:
Zip Code:
Card Number:
Exp. Date:
Verification #:
<<< Last 3 digits on back of card
Registration accepted by mail, fax or in person. No phone registrations.
Mail:
WKU Study Away
C/O Cuba Photo Workshop 2017
Tate Page Hall 104
1906 College Heights Blvd, Bowling Green, KY 42101
Fax:
270-745-4499
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Havana Passage: A Photographic Workshop - January 2017
Registration
PARTICIPANT RESPONSIBILITY STATEMENT
 I have read all program material provided to me and have had the opportunity to inquire about the
program, and
 I have read and accept of the terms stated in the program details (Green Sheet), and
 I acknowledge that WKU shall have authority to cancel or terminate the program and/or related on-site
activity in accordance with its policies and best judgment with no refund guaranteed, and
 I am aware of the option to obtain personal liability coverage and may do so at my own expense; and,
 I understand that I am required to utilize transportation arranged by Western Kentucky University, and if I
choose a mode of transportation independent of that provided by WKU, I do so at my own risk and
expense; and
 I shall conduct myself in an appropriate manner, which does not infringe upon the rights and safety of
other participants of the program; and,
 I understand that WKU does not employ or retain on-site mental health professionals, and that I should
consult with my current mental health provider prior to engaging in a program to discuss the potential
stress of the program, and that I know that mental health treatment may not be accessible while on the
program, and,
 I represent that I am medically fit to engage in the required activity and travel, and
 I understand that Western Kentucky University may require medical information to be eligible to
participate in the Program and that I will provide the information as required, and voluntarily and willingly
participate, and
 I acknowledge that travel may entail risks of personal and/or bodily injury including death and property
loss, including those resulting from kidnapping, criminal activity, terrorist attacks, food or beverage
contamination, and I agree voluntarily to assume all risks including, but not limited to, accident, illness or
damage to my person and property to the extent not covered by insurance, or liability of third parties, and
 I authorize WKU to take whatever actions deemed warranted and appropriate regarding my health and
safety.
By submitting this Information, the Participant agrees to abide by WKU policies and agree to indemnify
and hold harmless Western Kentucky University, its employees, agents, and/or officers from any and all
loss, damage, or expense incurred as a result of my participation in this program: Cuba Photo
Workshop 2017
Participant Print Name: _______________________________________________________________
Participant Signature:
____________________________________
Date: ___________________
If under 18, a parent or guardian must sign.
Print Name:
___________________________________________________________________
Signature:
____________________________________
Date: ______________________
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Havana Passage: A Photographic Workshop - January 2017
Registration
HEALTH INVENTORY – KEEP CONFIDENTIAL
Name:
Program Name:
800# (if WKU):
Cuba Photo Workshop
Start/End Date:
January 11 – 16, 2017 (tentative)
While you are not required to respond to the following, information on this page will be kept confidential and used only as necessary
to meet your needs or in a medical emergency.
Any health matters the Program
Leader needs to know about in case of
emergency?
List any medications taken on a daily
basis:
Please list any allergies you have:
(i.e. medication, food, etc.)
Please state any conditions of which
the Program Leader should be aware:
Please state any special dietary
requirements:
Please describe any special needs that
you require to participate in this
program?
Please state any other conditions that
could affect you while traveling (i.e.
phobias)
Do you wear the following? (check all
that apply)
Glasses
Contacts
Hearing Aids
Prosthetics
KEEP CONFIDENTIAL
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