Israel Summer Program
Student Registration Form

CHRISTIAN WORLDVIEW
Check this box to indicate that you have read & understand Regent Law's approach to teaching and that you agree to abide by the Christian Worldview statement.
NOTE: Each student must show proof of medical insurance (including repatriation provision) to be able to participate in the Israel program.
STUDENT INFORMATION
First Name
Middle Initial
Last Name
Address
City
State
ZIP
Day Phone
Evening Phone
Cell Phone
Email
Citizenship
Birthplace
Social Security Number
Summer Address (if different)
Banner I.D. number (if Regent student)
Passport Number
Passport Exp Date*
* Israel requires foreigners to have passports that are valid at least 6 months from date of departure for Israel.
Date of Birth
Are you a law student?
Yes
No

If law student, school name
If not law student, school & degree:
# semesters completed by
May 11, 2013
 
EMERGENCY CONTACT INFO
Name
Phone
Email
 
LODGING INFO
Requesting
Costs do not include airfare, lunches, personal expenses, etc.
 
DEPOSIT
Pay Deposit Online Now
 
(Amount $ )
Pay by Check (due within 2 weeks).