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Registration form for Program Participation Summer Programs - 2003
1. Name First _______________Last ___________________Middle ___________ 2. Mailing address _____________________________________TEXAS________ Street City State Zip3. Home phone _________ Work Phone ____________ E-mail______________
4. Occupation ____________________ 5. Marital status_____________________ 6. Sex_____________ 7. Age ________8. Citizenship ________________ 9. Person to notify in case of an emergency_______________________________ ____________________________________________________________________ Relationship Street City State Zip Home phone Work phone
10. Which ARTIS Program do you want to sign up for : Florence Italy 21 days ___ 30 days _____ 10a.Which section and dates do you want to sign up for? May 27-June 16_____or May 27-June 25 _____ 10b. According to your program choice you want to take: Hist. of Italian Art ____ 11. Are you willing to share a double room? YES_____ NO_____ 12. Do you prefer a single room at supplemental cost? YES_____ NO_____ 12a. Do you want to stay in safe/clean student quality apts. or dorm housing ? YES_____ NO_____ or do you want to upgrade to luxury accommodations at supplemental cost? YES_____ NO_____ 13. If you are a married couple are you willing to share an apartment with other married couples (private bedroom, common bath and kitchen)? YES_____ NO_____ or do you need a private apartment at supplemental cost? YES_____ NO_____ 14. During excursions are you willing to share a room with 2-5 people? YES ______NO ______ or do you need a private hotel room at additional cost? YES ____NO ______ 15. Do you smoke? YES_____ NO_____ 15a. Do you have dietary restrictions? YES_____ NO_____
16. How did you find out about the ARTIS Program? _____________________ 16a. If referred, whom may we thank? Give name ________________________ 17. Are you going to travel independently after the program? YES_____ NO_____ 17a. What is your exact return date to USA? (It should be on a Monday through Thursday) ____________ 18. Which city will you fly from to go to our port departure city (airport)? __________________________ 19. If on the airplane you need special meals, please list ___________________________________________ 20. (Florence Program only) at supplemental cost do you want to stay an extra night in Venice? Yes____ No ___ · Comments or things we should know._____________________________________________
FOR STUDENTS ONLY: 21. Do you need College registration info? YES______ NO______ 22. Permanent address ____________________________________________________________________ Street City State Zip 23. Academic Major ___________________ 24. College/School : SHSU 24a. Classification - Soph ____ Jr _____ Sr ___ Grad _______ Overall GPA _________ 25. Do you want credit college ? YES ____________ NO ____________ 26. Do you intend to apply for financial aid? YES _______ NO ________ |
GENERAL UNDERSTANDINGI understand that the accommodations are student quality apartments and/or dorm style type housing and that the hotels used during excursions are moderately priced small hotels. That apartment sizes and features along with their rooms may vary. That luxury accommodations may be requested, at additional costs, before April 1st. I understand that I am completely responsible for carrying my own luggage, that ARTIS does not provide porters and the use of any porters are at my own expense. I understand that the Excursion and Museum fees are paid by ARTIS based on the printed daily itinerary. I may attend whichever tour activities I wish, however there will be no refunds for missed tour activities or museums. If I choose to leave the tour for any reason or to travel independently of the group and/or tour itinerary I must take full responsibility for my decision and for any additional expenses I incur. This includes optional side trips to other locations and cities with or without group leaders that are not part of the printed itinerary. I understand that no smoking is allowed on the motorcoaches or in any accommodations where non-smokers are staying. Every effort will be made to place smokers together in the same apartments, however based on the order of sign-up, I may be required to pay the full single room supplement to be in with other smokers. (Or I will forego smoking to be in a non smoking apt.) Signature _____________________________________ Agreement to participate Assumption of risks I, the undersigned, am aware that participating in this program involves risks and dangers, including but not limited to the hazards of traveling, and accident or illness in remote places. I agree to follow guidelines set by ARTIS to provide for the safety and enjoyment of all participants and shall refrain from any behavior which might compromise my safety or the safety of another participant. I hereby agree to be responsible for my own welfare. I accept any and all risks of delay, unanticipated events, illness, injury, emotional trauma or death and verify this statement by signing here. Signature __________________________________ Signature of parent or guardian if under 21 -------------------------------------------- Date ___________________________ Date ___________________________ Medical statement 1) To the best of my understanding I am in good health and have no need for special assistance during the ARTIS tour. 2) I certify that I have enough prescribed medication to last for the duration of the program, if I am currently under medication. 3) I am capable of walking two miles a day and climbing stairs. 4) List any illness you have that requires daily injections or medication; i.e. diabetes etc. Signature ___________________Date_______ Doctor statement (for applicants over 70) I _______________________ MD certify that to the best of my knowledge _______________________________ is in good physical and mental health and does not require special assistance. That sufficient medication has been prescribed to last for the duration of the trip and that walking two miles a day or climbing stairs should not be a problem. Additional comments: Signature _________________________Date_________ Consent for Medical Treatment I, the undersigned, hereby authorize and consent to any first aid, medication, medical treatment or surgery deemed necessary in case of an emergency. Signature ______________________Date____________ Signature of parent or guardian if under 21 ______________________________Date___________ Waiver of Liability In consideration for my participation in this program, I, intending to be legally bound, do hereby for myself, executors, and administrators waive, release and forever discharge and hold harmless ARTIS and Sam Houston State University( SHSU) for any rights and claims for damages, including any claims for less, damages or injury to my person or property arising out of my performance or failure of performance . Therefore as lawful consideration for being permitted to participate in this program and I hereby release and discharge ARTIS, SHSU and its agents and employees from and against any and all liability arising from my participation in the program. Signature ___________________________________ Signature of parent or guardian if under 21 -------------------------------------------------- Date ____________________________ |
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LIMITATION OF LIABILITY ARTIS gives notice that all services (Hotels, airlines, trains etc.) provided for our program are by independent suppliers over which ARTIS and SHSU has no direct control. That ARTIS acts only as an agent with the understanding and condition that ARTIS and SHSU shall not be liable for any delay, mishap, inconvenience, expense, bodily injury or death, or damage to property.
ARTIS and SHSU shall not be liable for any expenses whatsoever beyond what is specified in the program itinerary, before, during or after the program. ARTIS and SHSU shall not be liable, directly or indirectly for bodily injury, death or property damage for any reason over which it has no control.
ARTIS reserves the right to take photographs or videos of our programs and to use such photographs for promotional purposes.
Return application forms and fees (in the form of checks or money order made payable to ARTIS) to:
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