American Culture and English Program (ACE)

American Culture and English Program (ACE)

Registration Form

The program is open to students who applied and received admission to MWSU for the Fall 2016. Program fees includes 7-day shared on-campus room/accommodation, most meals, daily classroom instruction, reading materials, local area trips, program activities, local transportation, airport pick-up, and medical insurance from August 15-21, 2016. Please send the registration form along with the program fee payment (credit card, wire transfer, bank draft, or personal check drawn from a U.S. bank) to Missouri Western State University. The completed and signed form may be scan/email to Ms. Patty Kuechler at , OR fax to +1-816-271-5922, OR mail to the address above. Refund requests must be received no later than Monday, August 8.

PROGRAM FEE AND DEADLINE: ☐$500 Early Bird Discount by July 15 ☐$525 Regular Fee by August 1

Student Full Name: Click here to enter text.Student G number: GClick here to enter text.

Sex: ☐Female ☐MaleEmail: Click here to enter text.

T-Shirt size (free to student): Choose an item.Dietary restrictions: Click here to enter text.

Emergency contact name, and phone number: Click here to enter text.

PROGRAM CONDUCT AGREEMENT:

I promise to abide by all rules and accept the full authority of the ACE program director, Ms. FumiMatsumoto Cheever.

Student’s signature: ______Date: Click here to enter a date.

Let us know the name of a friend who is also an ACE participant: Click here to enter text.

Let us know if you have a disability that would limit or prohibit participation in theevent. We will contact you promptly to discuss appropriate accommodations. Click here to enter text.

PARENTAL OR GUARDIAN PERMISSION/RELEASE FORM (for studentUNDER the age 18 years old):

In signing this form, I give permission: 1) for my child to be transported in University vehicles for approved off-campus activities, 2) for my child to be receive health, medical and/or surgical treatment when such is recommended by an official medical professional, and 3) for my child to be photographed or videotaped for program advertising purposes. In case of an emergency, I understand every effort will be made to contact parent or guardian as named.

Parent’s name: Click here to enter text.Phone: Click here to enter text.

Email: Click here to enter text.Address: Click here to enter text.

Parent’s signature: ______Date: Click here to enter a date.

Type: ☐American Express ☐Discover ☐MasterCard ☐VisaEmail for receipt: Click here to enter text.

Credit card number (16-digit): Click here to enter text.Expiration date (MM/YYYY): Click here to enter text.

Name of card holder: Click here to enter text.CVV (3-digit code on back of card): Click here to enter text.

Street number/postal code where bill is received: Click here to enter text.

MWSU is an equal employment, educational opportunity, and tobacco and smoke-free institution.