Application for Regent Hollywood Experience
Application Deadline January 27, 2017

You must fill this form out completely.* Comments optional.

Application Request


Your First & Last Name:*
Student ID:*
Email Address:*
Local Address:*
Cell Phone:*
Gender:* Male

Are you a SCA alumni?* Yes

Which of these courses will you have completed before May 3?*


SSW510 (preferred)


Which writing sample will you submit with your application?* Short film script or television script
Feature film script in lieu of short film script or television script
Regent University students please answer the following questions.
Which Regent University school(s) are you enrolled in (please list any joint degree schools): School of Business & Leadership
School of Communication & the Arts
School of Divinity
School of Education
School of Government
School of Law
School of Psychology & Counseling
School of Undergraduate Studies
When do you plan to graduate? (If alumni, what year did you graduate?)*
Are you a Distance or On-Campus student?* Distance
Are you taking this course for Credit or Non-Credit?* For Credit
Have you talked to your student advisor to confirm that these courses will be used toward your degree?* Yes

Who is your faculty mentor for your current Regent Program? (if alumni, enter N/A)*


Regent University
School of Communication & the Arts
Attn: Margie Ackerman
1000 Regent University Drive, COM 240
Virginia Beach, VA 23464
Fax: (757) 352-4291

I understand that all applicants must go through the approval process before they can be accepted into the program. Regent students confirmed to be in good standing by Student Services and the Business Office will be permitted to attend this course if they are accepted.
Health Insurance for all Participants

I am 100% responsible for securing my own medical coverage prior to the travel date. I am responsible for any medical emergency and expense during this trip. I should take a copy of my insurance card when traveling.
Travel Release Form

I have reviewed, completed and signed the Regent University Travel Release Form. I will forward a copy of the completed form to Margie Ackerman by January 27, 2017.
Photo Release Form

I grant Regent University the right to take pictures of me and my property and to use such photographs as publicity, illustration, advertising and Web content. I will forward a copy of the completed Photo Release Form to Margie Ackerman by January 27, 2017.
Minimum Number of Participants

I understand that unless a minimum of 10 applications with deposits have been received by the deadline of January 27, 2017, the trip will be cancelled and a full refund of the program fee will be issued to me.
Health Advisory & Special Accommodations

I understand that this program can be rigorous, and some of the events may require demanding physical activities. Therefore, participants should possess the ability to:

  1. Walk one mile without resting. Students walk to & from class each day, approximately 1 mile each way.
  2. Stand for 30 minutes without sitting
  3. Climb three flights of stairs without assistance. Park LeBrea Apts. have been known to have elevators break down. Each building has 12 floors.
  4. Hear instructions in a group setting with environmental noise present
  5. Read and understand written instructions and signs
  6. Step in and out of buses or shuttles
  7. Endure smog in various areas

Regent University may be unable to provide special accommodations for people with disabilities. Any person who believes he/she may need special accommodations must contact the Disability Services Coordinator to discuss his/her needs in advance, with ample time to make appropriate accommodations as needed. If a person needs personal assistance during the trip, that person must bring a companion/assistant at full price. If I have any questions regarding special accommodations for people with disabilities, I will contact Robbie Kuschel at 757-352-4894 or at

Regent University does not assume liability for injury, damage, loss, accident, delay, or irregularity which may be occasioned by reason or defect, through the acts or defaults of any company or person engaged in conveying the participants of this tour or in carrying out the arrangements of the tour, or as direct or indirect results of acts of nature, breakdowns in machinery or equipment, acts of governments or other authorities, de jure or de facto, wars, whether declared or not; hostilities, civil disturbances, strikes, riots, theft, pilferage, epidemics, quarantines, medical or customs regulations, loss or damage resulting from improper passports, visas, or other documents or from any causes beyond the control of the University. The University can accept no responsibility for loss or additional expenses due to delay or changes in schedule or other causes. We have the right to refuse to accept or retain any tour participant should such person's health or general deportment impede the operation of the tour to the detriment of other participants. All rates are based on tariffs in effect at the time the tour was planned and are subject to change in the event of adjustments therein. Baggage is carried at the owner's risk and baggage insurance is recommended. The issuance of tickets and vouchers will be deemed to be consent to the above conditions.

The participant's signature below (type your name) and participation in this trip constitute acceptance of this provision and agreement by such participant that Regent University shall not be liable or responsible in any way whatsoever for any inconvenience, loss, damage, or injury arising out of or in connection with such tour services. By typing my name below, I acknowledge that I have read and fully understand the conditions and responsibility area of the enrollment application and verify the information I have provided as truthful and correct.

Type Name:*