Please print this page
and write in black ink.
Provide proper payment as outlined in Section B and if paying by check, make it
payable to Dixie State College Travel Study.
Be sure you have read the Payment schedule and refund policy set forth in this
application. Be sure to read and sign the enclosed Agreement and Release.
Get your passport at http://travel.state.gov
Return form to: Kelly Bringhurst
Dixie State College
225 S. 700 E.
St. George, UT 84770
kbringhurst@dixie.edu
office: 435-652-7768
FAX: 435-656-4022
Name:
Street address:
City, State, Zip Code
Telephone # (day)
Telephone # (night)
E-mail address:
Citizen of:
Date of Birth:
Male/Female
Passport No.
(passports must not
expire within 6 months after date of entry into Costa Rica)
I wish to share a room
with _________________ or please assign a roommate.
Emergency contact
while abroad:
Relationship:
Name:
Street address:
City, State, Zip Code
Telephone # (day)
Telephone # (night)
Course fee of $2095 covers transportation
to and from St. George, Utah to Costa Rica,
travel within Costa Rica, lodging in Costa Rica, meals in Costa Rica, and
scheduled activities.
It does not cover normal Dixie State College tuition and fees, meals while in
transit to
Costa Rica, snacks or drinks
between meals, optional activities,
Costa Rican departure tax (currently $26) or incidental personal expenses.
All payments are to be paid to the Dixie State College Cashiers Office,
Account: USH600-750200
Deposit:
A non-refundable deposit of $250 is due by October 26, 2007.
This deposit is paid to the airline and tour company in Costa Rica, and
reserves your space.
List
any medication you are taking (this is for emergency purposes only and will be
confidential.)
Traveling in the jungles of Costa Rica requires a great deal of physical mobility.
Do you feel that you are able and willing to perform the essential functions of
studying abroad with or without accommodation?
If with an accommodation, please describe the accommodation that you would
need and how this would enable you to participate.
Do you have any allergies or chronic ailments that the Program Coordinator
should be aware of?
Do you have any special dietary needs? If so please describe:
RESPONSIBILITIES & CONDITIONS: Dixie State College and its agents, affiliates, cooperating airlines and agencies act only in the capacity of agents in all matters of transportation and tour operation, and their liability is limited to the terms of the airline tickets and land accommodation contracts. They are not liable for any delays, inconveniences, accidents, expense, or mishap of any kind whatsoever resulting entirely, or in part, from the negligence of others or from causes beyond their control. They can accept no responsibility for losses or additional expenses due to delay or changes in air or other services, sickness, weather, strike, war, quarantine, or other causes. Losses or expenses will have to be borne by the passenger since tour rates provide for arrangements only for the time stated. Personal travel insurance is strongly recommended. The right is reserved to substitute accommodations or modes of transportation and to make changes in the itinerary when necessary. On tours of this type, it is not possible to accommodate persons with health problems or physical disabilities which limit walking or other activities. One must assume the risks inherent in foreign travel to less developed areas of the world. It is the passenger’s responsibility to judge the appropriateness of these travel activities in conjunction with his/her physician. Dixie State College and affiliates take no responsibility for special arrangements or problems incurred by passengers physically unable to participate in planned activities, or with special dietary needs. No refund can be made for absence from the tour. The right is reserved to decline to accept or to retain any person as a tour member for any reason which affects the operation of the tour or the rights and welfare or enjoyment of the other tour members.
The price of the
tour is based on current tariffs and exchange rates and is subject to
adjustment in the event of any change therein. Baggage is at the owner’s
risk entirely. If the entire program must be canceled, participants shall
have no claim other than for a full refund.
I have given truthful
information, and agree to fully participate in the program.
Signature
_________________________________ Date _________________
For
more information contact Kelly Bringhurst: kbringhurst@dixie.edu