ENROLLMENT APPLICATION
LEADERSHIP HONORS BOOTCAMP
May 18-23, 2014
Washington, DC Metro Area
Enrollment Deadline: March 31, 2014
INSTITUTION INFORMATION
Name of Nominating Administrator/Dean: __________________________________________________________________________________________________
(Salutation)
Office Phone Number: (
(First)
(Last)
) ____________________________ E-Mail Address: _________________________________________________________________
APPLICANT INFORMATION
Applicant’s Full Legal Name: ______________________________________________________________________________________________________________
(Last)
(First)
(Middle)
Major: ______________________________________ ❑ Male ❑ Female Birthdate:______/______/_____
Month
day
Preferred Mailing Address: ❑ Permanent ❑ Campus
year
Permanent or Home Address: ______________________________________________________________________________________________________________
(Street)
Home Phone Number:
(
(City)
(State)
(Zip Code)
)_______________________________ E-mail Address: ________________________________________________________________
Name of College or University Currently Attending: _________________________________________________________Expected Year of Graduation:___________
Your Campus Address (if different from above):
Campus Phone Number: (
) ___________________________
____________________________________________________________________________________________________________
(Street)
(City)
(State)
(Zip Code)
EMERGENCY CONTACT INFORMATION
In case of emergency, please notify: __________________________________________________________________(_______)________________
(Name)
(Relationship to Applicant)
(Phone Number)
ACCOMMODATIONS
Assign a roommate who is: ❑ a non-smoker ❑ a smoker ❑ either
Do you have any special dietary requirements? ❑ Yes ❑ No
If yes, describe: __________________________________________________________________
_______________________________________________________________________________________________________________________________________
Do you have any special medical needs? ❑ Yes ❑ No
If you answered yes, please detail your physical or psychological conditions and the necessary special accommodations on a separate sheet and attach it to your
completed enrollment. Please include information about prescribed medications. A staff member will be in contact with you to discuss the extent of your needs and if
accommodations can be made available.
PAYMENT INFORMATION
Tuition is $1,975 and includes instruction and program materials, carefully selected accommodations, and two meals per day. The tuition is non-refundable.
Indicate your method of payment below:
❑ Enclosed is a check or money order for the full non-refundable payment of $1,975. Make check or money order payable to: Honors Bootcamp and staple it to the
top of this page.
❑ I authorize the full payment of $ 1,975 to be charged to a credit card.
❑ Master Card ❑ Visa
3-Digit Card Verification Value on back of card immediately after the card's account number ____ ____ ____
❑ American Express
4-Digit Card Verification Value on front of card above the card's account number ____ ____ ____ ___
Card Number: ____ ____ ____ ____–____ ____ ____ ____–____ ____ ____ ____–____ ____ ____ ____
Expiration Date:_____/_____
Payee Information: _______________________________________________________________________(_______)__________________________________
(Name as it appears on credit card)
(Phone Number)
____________________________________________________________________________________________________________________
(Street Address)
(City)
(State)
(Zip Code)
Payee Signature: ____________________________________________________________________________________Date____________________________
Upon receipt of this completed enrollment application and payment, you will be sent materials that provide you further details on preparation for your
participation in an Honors Bootcamp program.
I, the applicant named above, have read and agree to the Information, Release and Agreement as stated on the second page of this application.
Signature ____________________________________________________________________________ Date _____________________________
Return by March 31, 2014 to:
Honors Bootcamp, 6501 E. Greenway Parkway, Suite 103-541
or e-mail to: nwhite@workshopaz.com
(Continued on next page)
HONORS BOOTCAMP
TUITION
INCLUDED IN THE PROGRAM COST:
Instructions – Expert facilitation and educational materials
Accommodations - Carefully selected accommodations
Meals - Two meals per day throughout the Honors Bootcamp program
Tips and taxes - All fees, tips and taxes levied by hotels, restaurants, scheduled sites and local governments, where such tips and taxes are the same for all participants of the group
NOT INCLUDED IN THE PROGRAM COST:
Transportation - participants are responsible for their own transportation to the program city in time for the start of the program. Specific details concerning the exact program starting
place and time will be provided to each enrolled participant. Transportation during free time is not included in the tuition.
BAGGAGE
Applicants are at all times responsible for handling their own luggage.
PAYMENTS
Applicant must submit full tuition with a completed enrollment form. Applicant understands and agrees that this enrollment form must be received by Honors Bootcamp no later than the
enrollment due date, accompanied by the tuition. There is a $20 non-refundable fee for returned checks.
Applicant understands and agrees that Applicant’s participation entitles Applicant to the standard arrangements and activities offered and/or scheduled by Honors Bootcamp including, but not
limited to, housing, meals, and educational materials. Generally, special arrangements and/or requirements desired or required for Applicant must be independently provided and Applicant
must bear the cost of any and all special arrangements and requirements. Honors Bootcamp, however, will comply with all U.S. Federal, state and local laws in connection with this Release,
including the Americans with Disabilities Act.
PARTICIPANT CANCELLATIONS
Should you need to cancel for any reason, the opportunity to participate and respective tuition fee is transferable to another student from your same institution but is not refundable. Any
cancellation or substitution of a participant must be submitted in writing and approved by the Honors Bootcamp prior to the beginning of the Leadership Honors Bootcamp program.
POSTPONEMENT OR CANCELLATION OF THE PROGRAM
Honors Bootcamp reserves the right to modify, postpone or cancel a program because of health, safety or other issues including, but not limited to acts of God, acts or omissions of government
authority, compliance with government regulations or any other cause or event beyond the control of Honors Bootcamp. In the event that Honors Bootcamp postpones the program, tuition
payments received prior to the postponement will be applied to new program dates.
In the event that Honors Bootcamp cancels the program, tuition payments received prior to the cancellation will be refunded.
HONORS BOOTCAMP
INFORMATION, RELEASE AND AGREEMENT
RESPONSIBILITY
In consideration of being accepted as a participant in an Honors Bootcamp program, the undersigned hereby releases Honors Bootcamp and its directors, officers, management, employees,
agents, and affiliates from any and all liability arising out of undersigned’s participation in the Program, and Participant further agrees to indemnify and hold harmless Honors Bootcamp and its
directors, officers, management, employees, agents and affiliates for any loss, damage, costs, or expenses which Honors Bootcamp may incur which are caused directly or indirectly by the
actions of the Participant.
RELEASE INFORMATION
Participant further grants Honors Bootcamp permission to use photographs, videotapes or movies taken in which Participant may appear in connection with the Honors Bootcamp, as well as
permission to utilize any information obtained by Honors Bootcamp on Participant through Participant’s registration in an Honors Bootcamp program for marketing and other purposes.
Purposes may include providing said information to the media upon the request of a reporter/producer.
EMERGENCY MEDICAL AUTHORIZATION
I, hereby request, authorize and give permission, to Honors Bootcamp or its duly authorized representative, to act on my behalf and in my stead, should I become ill, be injured or require
emergency or other medical treatment, including hospitalization, during the program. I understand that in any such event, if required or appropriate, I will be taken to a hospital emergency
room and examined by an emergency room physician. When seeking medical treatment, I understand that Honors Bootcamp will use reasonable judgment under the circumstances and will
defer to the expertise of any medical practitioner who provides services to me. I hereby authorize Honors Bootcamp and its agents to sign, on my behalf, as guarantor of payment of any
medical treatment I may require. I expressly stipulate and agree that I will be solely responsible for all expenses incurred as a result of any accident, illness, or injury incurred, and will
reimburse Honors Bootcamp and its officers, directors, employees, agents, affiliates, successors and assigns, from all claims, demands, damages, expenses, whether known or unknown,
resulting from, rising out of, or incident to the Honors Bootcamp’s actions pursuant to this authorization.
APPLICANT CODE OF CONDUCT STATEMENT
I understand that Honors Bootcamp is a professional program and as such demands the highest standards of behavior. I will conduct myself in a manner that will contribute to a sense of
community among all participants and foster an atmosphere of mutual respect. I agree to follow the instructions of the Honors Bootcamp staff at all times and participate in all professional
activities and meetings. I understand that an infraction of these guidelines may result in my immediate dismissal, return home at my expense, and forfeiture of all tuition paid.
IMPORTANT REMINDERS

As we are unable to process incomplete applications, please provide all of the information requested on the front of the application.

You should keep a copy of this application for your records.

All Applicants must be age eighteen or older by the start of the program.