WeCare/AN HBCU Tour Registration
Cost: $550 to reserve a spot a $100 nonrefundable deposit is required. The Cost includes: Motor Coach Transportation, Hotel Accommodations, HBCU Tour T-shirt, Breakfast & Lunch Daily. Tour will be held April 1st to April 4th Contact Brenda: (856) 535-4918 or Antoine: Info@AntoineNelson.org
Student Name
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Student Email Address
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Gender
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Male
Female
Student Grade Level
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9th
10th
11th
12th
Street Address
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City & State
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Student Date Of Birth
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Name Of School Student Attends
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Parent/Guardian Name
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Parent/Guardian Phone Number
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Parent/Guardian Email Address
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Emergency Contact Name
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Emergency Contact Phone Number
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Student T-Shirt Size
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XS
S
M
L
XL
XXL
Medical Insurance Provider
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Medical Insurance Policy Number
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Please list any medical problems, including any requiring maintenance medication (i.e. diabetic, asthma, seizures).
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Is your child presently being treated for an injury or sickness, or taking any form of medication for any reason? If yes, please explain.
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Is your child allergic to any type of food or medication?
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I understand that I will be notified in the case of a medical emergency involving my child. In the event I cannot be reached, I authorized the calling of a doctor and the providing of necessary medical services in the event my child is injured or becomes ill. PLEASE INITIAL BELOW
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I understand that WeCare/AN College Tour personnel will not be responsible for the medical expenses incurred, but that such expenses will be my responsibility as parent/guardian. PLEASE INITIAL BELOW
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I hereby give permission for my child to be photographed during the WeCARE/AN COLLEGE TOUR. I understand the photos will be used to keep a journal of activities, and for promotional purposes including flyers, brochures, newspaper and on the internet. I understand that his/her identity will not be disclosed, I do not expect compensation. PLEASE INITIAL BELOW
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WeCARE/AN COLLEGE TOUR are not responsible for lost or damaged personal property. All scheduled events are subject to change. I understand that no fees will be refunded or transferred unless a child is unable to participate due to an accident or illness per physician orders. Students photos and quotes may be used for publicity purposes. In case of an emergency, and if a family physician cannot be reached, I hereby authorize my child to be treated by Certified Emergency Personnel (i.e. EMT, First Responder, and/or Physician). PLEASE INITIAL BELOW
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REGISTRATION INFORMATION -$550 to cover lodging, food, activities, and transportation costs. $100 nonrefundable deposit to secure seat
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I agree
Payment
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