SLL Registration for New York City
Program Name
Society for Lifelong Learning New York Adventure
Program Dates
June 10-14, 2016
Today’s Date:
Name1:
1
Your name exactly how it appears on government-issued ID such as driver’s license
Email:
Phone (mobile):
Alternate Phone:
Gender:
DOB:
Street Address:
City:
State:
Zip:
Roommate(s):
PAYMENT
Double occupancy
Deposit:
$250
Date rec’d________________
Balance Owed:
$1325
Study Away Office to bill.
Please circle preferred
method of billing.
CHECK or CREDIT CARD
Total Program Cost:
$1575
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 scan/email, mail, fax or in person. No phone registrations.
Questions? Find more information at: http://www.wku.edu/americantraveler/programs/lifelonglearnersnyc2016.php or Dr. Cindy Ehresman at
270-745-1910.
Please return completed application to:
Society for Lifelong Learning Office
Knicely Conference Center 123
2355 Nashville Rd, Bowling Green, KY 42101-4144 (link for map)
Phone: 270-745-1910
Information
EMERGENCY CONTACT INFORMATION
Name:
800# (if WKU)
Primary Phone:
Email:
Address:
City:
INSURANCE INFORMATION
State:
ZIP:
DRIVERS LICENSE INFORMATION
Provider:
License Number:
Insured:
Exp Date:
ID Number
Date of Birth:
Group
Endorsements or
Restrictions:
REFUND POLICY
Refunds are normally processed through WKU’s Cashier’s office and will be made as a check mailed to the participant’s
designated address. Refunds may be offered in limited circumstances: CANCELLATION: If the program is cancelled by WKU prior
to departure, the participant shall receive a refund of amount paid, less any non-recoverable costs (i.e. deposits and prepayments, etc.) incurred and/or committed on the participant’s behalf by WKU and its affiliates at the time of cancellation.
NON-ACCEPTANCE: If a participant is not accepted prior to registration, the participant shall receive a full refund, which
normally would include only the initial payment. REVOCATION OF ACCEPTANCE: If a participant’s acceptance is revoked for any
reason, the participant shall receive a refund of amount paid, less $500 and any non-recoverable costs (i.e. deposits and prepayments, etc.) incurred and/or committed on the participant’s behalf by WKU and its affiliates at the time of cancellation.
POST PROGRAM START: No refunds will be considered after the program start date. WITHDRAWAL PROCESS. If, for any reason,
a participant chooses to withdraw from a program, a Study AWAY Office Withdrawal Form
(http://www.wku.edu/studyaway/apply-now/study-away-withdrawal-request/) must be completed by the participant. No
other statements of withdrawal will be considered as notification of withdrawal; therefore, the participant will still be
considered a program participant until this official notification is received by the SAO. Refunds will be based on the date that the
Withdrawal Form is received by the Study AWAY Office. If a participant withdraws from a program 120-90 days prior to
program start, he/she will be refunded amount paid, less $125 and any non-recoverable costs (i.e. deposits and pre-payments,
etc.) incurred and/or committed on the participant’s behalf by WKU and its affiliates at the time of withdrawal. If a participant
withdraws from a program 89-31 days prior to program start date, he/she will be refunded amount paid, less $250 and any
non-recoverable costs (i.e. deposits and pre-payments, etc.) incurred and/or committed on the participant’s behalf by WKU and
its affiliates at the time of withdrawal. No refund within 30 days of program start date. EXTREME CIRCUMSTANCES: In the
event of extreme circumstances, the Study AWAY Program Director will review the situation on a case-by-case basis. At the
discretion of the Program Director, any funds that are recoverable and uncommitted MAY be refunded, less $125.
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Information
PARTICIPANT RESPONSIBILITY STATEMENT
I have read all program material provided to me and have had the opportunity to make inquiry about the program;
and,
I am aware of the option to obtain personal liability coverage and may do so at my own expense; and,
I shall conduct myself in an appropriate manner, which does not infringe upon the rights and safety of the
participant and 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 understand that I may utilize transportation arranged by WKU or choose a mode of transportation independent of
that provided by the University at my own risk and expense; and
I understand that I am free to undertake independent travel, defined as travel I arrange on my own for nonprogram OR program-related activities, and understand that independent travel includes travel, separate from the
program leaders, on an “open” day as stated in the syllabus OR to/from a program site, and understand that all
aspects of independent travel are my responsibility, and acknowledge the risks and personal liability of undertaking
independent travel, and accept responsibility for my personal safety, health, legal aspects, and costs associated with
independent travel; 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 acknowledge that WKU shall have authority to cancel or terminate the program and/or related on-site activity in
accordance with its policies of best judgment with no refund guaranteed, and
I understand that my Program 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 represent that I am medically
fit to engage in the required activity and travel, and I further 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, ___________________________________ 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: ______________________________________________________
Date: _______________________
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Information
HEALTH INVENTORY – KEEP CONFIDENTIAL
Name:
WKU ID (if WKU)
Program Name:
Departure Date:
Information on this page will be kept confidential and used only as necessary to meet your
need or in 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
KEEP CONFIDENTIAL
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Information
Reservations
Reservations 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.
Cancellation Penalties
Prior to May 1
After May 30
50% refund of payments less expenses pre-paid by Study Away
No refund
Cancellation must be received in writing (email preferred). No verbal cancellations will be accepted.
Program Includes
Includes lodging, admissions, round-trip air transportation (to/from BNA), and ground transportation to/from the airport
in New York City.
Not included
Not included in program fee: transportation to departure airport (Nashville), meals and personal spending money
Terms

Deposit due with paper application.

Balance will be due according to deadline listed on registration form.

Final program fee subject to change due to travel arrangements.

The group flight originates and returns to Nashville. Any individual deviation to the group flight may be at the
traveler's expense.
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 is a short-term, noncredit program through WKU Study Away designed to provide intense, unique
travel experience to fascinating locations. These learning opportunities are developed and led by experts and designed to
give participants a one-of-a-kind experience. WKU’s Study Away is a unit of Extended Learning & Outreach.
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