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Institute for Law, Justice & Society > EU & You Registration Form

EU & You Registration

This form should be utilized by students wishing to register for the EU & You trip to London, Brussels and Geneva, May 9-20, 2010.

Please fill out all required fields marked with an asterisk (*). At the conclusion of this form, you will be asked to pay a non-refundable $250 deposit. This money will be applied toward the cost of your trip.

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Personal Information
* First Name
* Last Name
Social Security Number
* Lipscomb ID
* Gender	Male Female
* Date of Birth
* Classification in Fall 2010	FR SO JR SR
* Major 1
Major 2 or Minor
Course you will enroll in	Business Political Science LJS
* Preferred email address
* Other email account
* Home Phone
* Cell phone
Parental Information Please provide this information if you are a traditional undergraduate student (not an adult learning student). All information is required.
Mother First Name
Mother Last Name
Mother Address 1
Mother Address 2
Mother City
Mother State
Mother Zip
Mother Home Phone
Mother Cell Phone
Mother Work Phone
Mother E-mail Address

Father First Name
Father Last Name
Father Address 1
Father Address 2
Father City
Father State
Father Zip
Father Home Phone
Father Cell Phone
Father E-mail Address
Father Work Phone
Travel Information
* Do you have current passport?	Yes No
Current Passport Number
* Have you traveled internationally?	Yes No
If yes, where have you traveled and for how long?
* Do you have frequent flyer with United Airlines?	Yes No
If yes, what is your United frequent flyer number?
* What is your seat preference?	Window Aisle
Do you have dietary requests for the flight?
Insurance & Medical Information
Medical Insurance Provider
Policy Number
Group Number
Does your insurance include international coverage?	Yes No
Emergency Contact Name
Relationship to Emergency Contact
Emergency Contact Home Phone
Emergency Contact Cell Phone
Second Emergency Contact Name
Relationship to Second Emergency Contact
Second Emergency Contact Home Phone
Second Emergency Contact Cell Phone
Do you have medical conditions that could impact trip? Please explain fully.
Describe any allergies you have.
Agreement to Participate
By checking this box, I understand that I am making a $250 non-refundable deposit to be applied to the cost of the trip. I also understand that by participating I will be expected to abide by all Lipscomb University rules regarding behavior during the trip. Failure to do so will result in the appropriate disciplinary action, up to and including dismissal from the program. I understand that in the case of dismissal from the program, Lipscomb University is under no obligation to refund any portion of the costs of the program. The cost to return home early will be the full responsibility of the student
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Personal Information

Parental Information

Travel Information

Insurance & Medical Information

Agreement to Participate