DC/NYC Trip March 3rd – 10th
Start Date/Time: End Date/Time:
Fee per Student: Room:
* - denotes required fields
Family Information
First Name:* Last Name: *
Home Phone: Cell #: Work #:
Email:* (Emails are kept confidential)
Address: *
City: * State: * Zip: *
Emergency Contact Info*
Students entered below will be added to your family's account
Traveling with parent/guardian?*
Please list any allergies (e.g. to Medications, Food)*
Child’s Health Information: Please list physical/mental health conditions (e.g. Asthma, Diabetes)*
Please list any prescription medications.*
Please list the following: Insurance Company Name, Policy/Group Number, Policy Holder. Email Photocopy of Insurance Card to*
Additional Information:
Other Questions/Comments:
Credit Card Verification:
Card Number: *  
Name as it appears on card: *
Card Expiration Month: *   Exp Year: *
Address Line 1: Address Line 2:
City: State: Zip:*