Application (How Broadway is Changing with America)

Contact Information

Name*

First Last

Preferred Name*

Email*

Mobile Phone*

Date of birth*

As an adult education school, learners must be at least 18 years of age to participate in our programs.

Mailing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Emergency Contact

Emergency Contact Name*

First Last

Emergency Contact Relationship*

Emergency Relationship Phone*

Emergency Contact Email*

Insurance

Vacation Cancelation Insurance*

Note: the Graham School does not offer this insurance.

I have/will purchase vacation cancelation insurance.

I will be waiving vacation cancellation insurance.

Do you have a disability or health condition that may require accommodations to support your full participation in this program?*

Yes

This information is collected solely to ensure appropriate support and accommodations can be provided. It will be kept confidential and will not affect your eligibility to participate. Participants should be aware that the trip requires considerable walking. Ability to climb 2 -3 flights of stairs and ability to stand for up to 60 minutes is required.

Please describe any special need/support required to assist you with your study.

Participants should be aware that the trip requires considerable walking. Ability to climb 2 -3 flights of stairs and ability to stand for up to 60 minutes is required.

Room Accommodations

I acknowledge that the program fee of $3,990 per person includes accommodations.

Application

Contact Information

Emergency Contact

Insurance

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