Short Term Study Registration Form- Minors

Short Term Study Registration Form

ESLI at UMD
Student Information
Name

First Name Last Name
Birth Date

Month Day Year
Country of Citizenship
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Email
example@example.com
Gender

Male Female
Where are you currently studying?
What is your major?
What is your level of study?
Parent/Guardian Information
Name

First Name Last Name
Phone Number

Area Code Phone Number
E-mail
Emergency Information
Emergency Contact's Name

First Name Last Name
Relationship
Phone Number

Area Code Phone Number
Do you have any allergies, chronic illness, or medical conditions? If yes, please describe.
Please Upload Your Passport

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Terms and Conditions

I understand that my son/daughter will be required to participate in all classes and activities as outlined in the program schedule, and abide by the rules and regulations of the program.

I also understand that ESLI reserves the right to dismiss any student who does not abide by such rules and that such student will be returned home at their own expense and without a tuition refund.

I give permission to my son/daughter to participate in the full range of activities that will take place during the ESLI at UMD short-term program. I understand that my child’s photos may be taken throughout the program and that they may be used for future marketing purposes by ESLI.

I grant ESLI the right to make medical decisions for my child if I cannot be reached by phone immediately, and ESLI is permitted to sign activity waiver and release forms deemed necessary to participate in the program my child is registered in, on my behalf.

I certify that my answers are true and complete to the best of my knowledge.
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Student Signature: By signing this application, I understand and agree to abide by the Terms and Conditions.

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Parent Signature

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