China Study Trip 2016 - Participant Information Form
First Name:
Middle Initial:
Date of Birth:
Last Name:
Gender:
Address:
City:
State:
Phone:
Email:
Emergency Contact Name:
Zip:
Emergency Contact Phone:
Preferred Roommate: (leave blank if you don’t know)
Single Room Upgrade:
Yes
No
Name EXACTLY as it appears on passport:
Passport - Country of Origin:
Passport - Number:
Expiration Date:
Comments:
Contract Agreement
I understand that, in the event that I cancel my participation in the trip, I will still be financially responsible for
any China Study Trip payments that AOMA Graduate School of Integrative Medicine (AOMA) has made in my
name. I agree to reimburse AOMA for these costs in a timely manner.
Signature ______________________________________________ Date ______________________
Please return this form to Julia Aziz along with a copy of your passport
A $500 deposit should be remitted to Shavana Walters
(Deposits will only be refunded if the trip is cancelled by AOMA.)
May 22, 2015: Early Registration Deadline—Receive a $100 discount on your final trip fee!
September 30, 2015: Final Registration Deadline