Young-adults Can Achieve
Student Registration Form
**$75.00 Deposit must accompany application and will be applied to your University tour balance. **
P.O. Box 168 Elmwood Park, NJ 07407
Please Print All Information in Ink
Application must be completely filled out for participation
I.
First Name
Last Name
Street Address
City, St
Home Phone
Cell Phone
Date of Birth
Age
II.
High School
Grade
Sex: M or F
Zip
Shirt Size: S M L XL 2X 3X
Email
GPA
SAT/PSAT
Major/ Career interest:
List College(s) of Interest:
III. Essay
Please describe why you are interest in attending the Young-adults Can Achieve University Tour
Program. Essay must be at least one 500 characters or 100 words. Do not submit this
application without completing the essay and checking for grammatical errors.
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IV. Parent or Guardian Information:
First & Last Name
Relation to Student
Home Phone
Alternate Phone
Emergency Contact Person (if parent or guardian cannot be reached):
First & Last Name
Relation to Student
Home Phone
Alternate Phone
V. Rooming & Roommates Preference:
Students will be assigned same sex and (4) to a room with (2) queen size beds. Roommates are selected on
a first come first serve basis. Students can request a roommate on the provided space below. Only requests
made on this form will be honored. Students who do not identify a roommate preference will be randomly
roomed. Encourage friends with whom you may be interested in rooming with to attend the tour.
VI.
We are not refusing any participant the opportunity to attend the tour due to medical or special concerns.
However, no participant shall be denied, that we are aware of all medical and special concerns. Please list
allergies, medication and dietary restrictions: (epilepsy, asthma, pregnancy, diabetes, etc.) Indicate whether
your child has your permission to take such medication while attending the event. All students must have
their health insurance company and policy number on them at all times for emergency purposes
only.
List any foods you are allergic to and Dietary Preferences/ Restrictions
VII. Financial Obligation:
Reminder only breakfast and dinner will be provided for the students, NOT LUNCH you must bring
spending money to purchase lunch at the University. Please include name of student on check or money
order. Mail all payments, application and related materials to P.O. Box 168 Elmwood Park, NJ 07407
Parent/ Guardian please note there are two payment options listed below. Adhere to the
deadline dates and select which one you are submitting:



University Tour $275 payment deadline 3/15/2016 
Early Bird Special $250 payment deadline 1/15/16
Note: If you do not meet the 3/15/2016 deadline a $25.00 late fee will be applied.
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VII. Terms and Conditions:
I, the undersigned (and my parent or legal guardian), am applying to become a participant on a college
visitation tour program offered by Young-adults Can Achieve. I have read and agree to the terms and
conditions of this Young-adults Can Achieve participant contract, and acknowledge that it forms my soleagreement with Young-adults Can Achieve regarding responsibility, refunds, hotels and prices.
If I become sick or incapacitated Young-adults Can Achieve may take reasonable action including,
obtaining medical treatment for me. I acknowledge that I have health, life, and/or accidental death
insurance, which provide sufficient coverage for me while on my Young-adults Can Achieve trip. In the
event of the above, I agree to submit all claim forms to said companies who have written insurance policies
providing me this coverage and not Young-adults Can Achieve.
I will indemnify Young-adults Can Achieve, directors or chaperones and hold them harmless for any
financial liability or obligation which I personally sustain, or injury damage to the person or property of me
or others which I cause or contribute to causing while participating on this trip.
I understand that I am responsible for exercising caution & common sense at all times to avoid injuries. I
understand and agree as a condition of traveling on this trip that I (and anyone else claiming through me)
have no rights whatsoever, directly or indirectly, under any theory at law or in equity, against Young-adults
Can Achieves’, directors or chaperones for any losses. Injuries, damages, or other claims of any sort in any
way relating to or arising out of the Young-adults Can Achieve college trip. The above is inclusive of any
action or inaction on the part of Young-adults Can Achieve or its paid representatives except for its failure
to refund monies which may become due as a result of trip cancellation or personal medical reasons which
are documented to Young-adults Can Achieve prior to the start of the trip.
I understand the trip deposit is non-refundable. Trip fee refunds to me for medical or other reasons will be
made by a written request and received by Young-adults Can Achieve at least 10 days in advance of
departure of the trip. I understand Young-adults Can Achieve may not be able to refund total trip fees due
to non-refundable purchases made on my behalf for the trip (including the trip deposit amount).
I understand that Young-adults Can Achieve is not an agent of, and has no responsibility for, any third
party which may provide any services including food, lodging, travel, or other goods or services associated
with the Program. I understand that Young-adults Can Achieve may provide these services only as a
convenience to participants and that accordingly, Young-adults Can Achieve accepts no responsibility, in
whole or in part, for delays, loss, damage or injury to persons or property whatsoever, caused to me or
others prior to departure, while traveling or while staying in designated lodging. I further understand that
Young-adults Can Achieve is not responsible for matters that are beyond its control. I acknowledge that
Young-adults Can Achieve reserves the right to cancel the trip without penalty or to make any
modifications to the itinerary and/or academic program as deemed necessary by Young-adults Can
Achieve.
Sign Student’s Signature
Date
Sign Parent’s Signature
Date
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VIII. Photo Permission:
Your child is participating in the Young-adults Can Achieve University Tour. In order to celebrate and
advertise the good work and success of Young-adults Can Achieve and its participants, we may wish to
take photographs and/ or make video recording of your son or daughter for advertisement. Activities and
events that might include your child will be used for publications such as the prospectus, the website or
even for use in the media. These photos and/ or video recordings can serve as valuable resources in terms
of providing feedback to the performance, effectiveness and service of our organization.
Photography will only take place in the company of Young-adults Can Achieve Directors or Chaperones
and no images that may cause embarrassment or distress will be used. Personal information such as names
will not be included with any pictures unless additional permission is granted.
Please circle whether you give or do not give permission below and sign:
I have read and understand the above information. I hereby
GIVE PERMISSION / DO NOTGIVE PERMISSION
to Young-adults Can Achieve to photograph and/ or produce video recordings of
.
(Print Student’s Name)
Parent/ Guardian’s Signature
Date
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