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Faculty

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Study Tour of Israel & Jordan

Trip Registration - Part One

Use the form below to register for the study tour trip. After completing this form you will need to complete Part Two (deposit/payment).

First name
Middle name
Last name
Gender
Mailing address
Cell phone
Home phone
National citizenship
If Other, have you secured a travel visa?
Email address
Emergency contact person & their contact information
Passport number
Passport expiration date (must be valid for at least 6 more months from date of entry)
Airline [with flight arrival and departure information (if known)]
Room option
Name of preferred roommate (regardless of room option selected)
Health or medication issues that organizers should be aware of
Relationship to Regent University
Are you willing to sign an informed consent, acknowledgement of risk and assumption of liability form?

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