STUDY AWAY ---SHAKESPEARE 2010

DEPARTMENT OF LANGUAGES & LITERATURE

(Individuals traveling together may use the same form if all charges are to be made to the same account.)

Choose the one that describes you: Taking course for credit:

Current NSU student: ______ Yes: _____ No: _____

NSU Faculty/Staff: ______

Other: ______

Full name(s) as shown on Driver’s License: Driver’s License No. and State

_____________________________________________ _________________________

_____________________________________________ _________________________

Permanent Home Address: Date of Birth:

______________________________________________ _____________________

______________________________________________ _____________________

______________________________________________ Social Security Number:

Emergency Contact Information: (Name and Telephone number) ____________________

______________________________________________ ____________________

______________________________________________

Preferred e-mail Address: __________________________________

Home or Work Telephone Number: _______________________ Cell Number:____________________________

By signing this I agree to pay the amount of the trip. I understand that the Business Office at NSU will charge my personal account for the trip. I understand that I must have the trip fully paid off before I leave for the trip.

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Participant’s Signature Date

Contact Dr. John Mercer for questions concerning the Study Away-Shakespeare trip at: mercer@nsuok.edu Acct. # 039467