Paris & Provence 2008 Study Tour Application Form

Name (exactly as it appears on US Passport!) ____________________________________

Address ___________________________________________________________________

City _______________________State and Zip Code _______________________________

E-mail address ________________________ Passport number _______________________

Telephone (school) ___________________Telephone (home) ________________________

Emergency contact, incl. phone number _________________________________________

Do you have a travel partner that you’d prefer to room with? _________________________

Do you have allergies (esp. to certain medications)? ________________________________

Are you in good health and capable of extensive walking and climbing of stairs? _________

Do you have health insurance that covers you out of the country? _____________________

Registration. Please make out checks to “NSU French Study Tour 2008”

Total Cost $2441. $1000 non-refundable deposit by Dec 20. Balance ($1441) by Jan. 18

Mail to Office of Extended Studies, Northern State University, 1200 S. Jay St., Aberdeen, SD 57401 or fax to (605) 626-2635. Direct questions to Dr. Casey Black at 626-7697 or blackc@northern.edu

Hold Harmless and Indemnification

I agree to hold harmless and indemnify Northern State University, the South Dakota Board of Regents, and the State of South Dakota, their officers, agents and employees, from and against any and all actions, suits, damages, liability or other proceedings which may arise in connection with the France Study Tour Trip in March, 2008

I understand that Northern State University’s sole commitment is to the Special Projects that each student may elect to enroll in.

I understand that if there is a change in the exchange rate with the euro (currently $1.25) that my cost may be increased.

I acknowledge that I have been advised that I should purchase trip insurance.

Name: (print or type) ______________________________________________

Signature: _____________________________________ Date: ____________