Close Up Enrollment Form

2016-17 CLOSE UP ENROLLMENT FORM

Please type your name exactly as it appears on the ID you will bring on our program. This is necessary for travel purposes and for you to gain entry into some of Washington’s buildings.

Every participant must complete an enrollment form to participate in a Close Up Program. All students and minors should complete this form with a parent or guardian. The enrollment form consists of two pages. Your information will not be saved unless you complete both pages and hit ‘submit’. Upon completion of the form, you will be able to access other tools and resources including payment options, fundraising materials and program information. Thank you for choosing Close Up and we look forward to having you on program soon!

Please complete your enrollment form and print a copy to keep it handy for your own reference. All students and minors should complete this form with a parent or guardian.

Close Up welcomes participation on its programs without regard to gender, race, color, religion, sexual orientation, gender identity, national origin or disability.

The Close Up Program requires a level of education, maturity and independence of participants. Student must be capable of rooming with students from different parts of the country, keeping up with the intensity of program (8:00am-10:00pm each day), riding a charter bus throughout the week, participating in discussions on public policy issues, history and government with their peers throughout the day, attending seminars, following instructions on where and when to meet instructional staff for workshops, seminars, monument study time and meals and comfortable with the noise and crowds in Washington, DC and comply with all rules on program. I affirm that my student is capable of meeting these requirements.

I. STUDENT INFO

Please type your name exactly as it appears on the ID you will bring on our program. This is necessary for travel purposes and for you to gain entry into some of Washington’s buildings.

II. PARENT OR GUARDIAN INFO

III. STUDENT MEDICAL INFO

Your answers to these questions will remain confidential.

In order to attend our program, you must bring these items with you to Washington:

• A completed Medical Questionnaire and Consent for Treatment Form; and

• Your Health Insurance card or a copy of the front and back of your card.

Special arrangements require advance notice and planning. Are you: (check all that apply)

Do you have difficulty with mobility and/or require assistance to walk such as a wheelchair, crutches or cane?

For any questions or more information, please contact Sharon Hunter at 800-256-7387 ext. 3499 or at shunter@closeup.org.

IV. DEMOGRAPHICS

For educational and funding reporting purposes, Close Up requests that you provide the following demographic information. Such information will remain confidential and will not be used at any time for selection or placement criteria for the Close Up programs. Please complete all items below. Your cooperation is greatly appreciated.

NOTE: Please answer BOTH questions 4 and 5.

V. TERMS & CONDITIONS FOR PARENTS/GUARDIANS & STUDENTS

Please take a moment to read our terms & conditions and contact us at 800-256-7387 if you have any questions. Thank you.

I, the parent or guardian of the student (“Participant”) submitting this enrollment, request that Participant be allowed to participate on your program and agree to these terms:

1. CAPABILITY: I understand that Close Up’s program will require Participant to interact with students and Close Up staff in a variety of settings. Participant will engage in structured academic activities and “live and learn” with students that may be from other schools across the country. Participant may share hotel accommodations with students from other schools across the country. Close Up accommodations generally consist of four students to one room containing two beds. Participant is ready, willing and able to participate, to treat everyone with respect at all times and to follow Close Up’s rules at all times.

2. CONDUCT ON PROGRAM: Participant shall: (a) show respect at all times during the program, including to students, teachers, Close Up staff & vendors; (b) be in Participant’s hotel room before curfew; and (c) participate in all scheduled program activities unless previously excused by Close Up. Participant shall not: (a) enter a hotel room assigned to members of the opposite sex; (b) leave program or have visitors without prior written permission from parents; or (c) possess or use alcoholic beverages, illicit drugs, or firearms or weapons of any kind. If Participant violates any of these rules as determined by Close Up, I authorize Close Up to send Participant home at my expense and with no refund due.

Close Up also prohibits the use of any tobacco products or electronic nicotine delivery systems, e.g., e-cigarettes, while in Close Up hotels or participating on any component of the Close Up program. Violation of these rules may result in sitting out of a component of program or in expulsion from the program at my expense with no refund due.

3. TRAVEL INSURANCE: Close Up strongly recommends Participant purchase travel insurance through Travel Guard, America’s #1 travel insurer. This will protect Participant against delays, flight cancellations, and other travel-related issues, including illness that may prevent Participant from traveling. To assure the full promotion benefit of the policy, travel insurance should be purchased 15 days after making first payment. Participant may elect to purchase Travel Guard coverage up to 48 hours before the trip begins, but coverage is limited. To purchase travel insurance from Travel Guard, please select “TOUR/AIR PACKAGE” in the Airline field and “CLOSE UP FOUNDATION” from the list of Tour Operators once selected to purchase insurance package. Residents of Washington State must call Travel Guard at 800-826-4919 directly to buy this insurance. Please click here to visit Travel Guard’s website and purchase insurance.

4. VALUABLES: Participant is advised to leave valuables at home. Participant may share hotel rooms, meeting space, and buses with students from other schools and communities. Close Up is not liable for lost or stolen items or for any use of personal property, such as Participant’s cell phone, even if such use is by other program participants.

5. PHOTOS and LIKENESS: I consent to the use in any medium of Participant’s name, likeness, audio, video photograph or quotes including posting same on Close Up’s website. Close Up may use Twitter or other social media to interact with Participant regarding issues related to the program. I understand and consent to this use of social media by and with Participant.

6. CELL PHONES AND Ipods: I understand that Close Up’s program depends on groups of students working together in various learning environments and that cell phone use, iPod or other similar devices during such times interferes with learning opportunities. Thus, Participant shall keep his or her cell phone, iPod and similar devices turned off at all times during program. The exception to this rule is if the instructor specifically authorizes Participant to use his or her phone.

7. DAMAGES: I assume liability and full responsibility to pay for any and all damage to Close Up property or property of any Close Up vendor such as hotel, restaurant, seminar room or bus caused by Participant while on program. Hotel damage includes cleaning charges for Participant’s room in which there has been smoking as determined by the hotel while the Participant was on program. I will pay any and all charges for damage caused by Participant in accordance with the damaged vendor’s policy.

8. MEDICAL: If Participant, in the opinion of Participant’s teacher or Close Up or its delegate, needs medical consultation or treatment, I authorize such consultation or treatment and authorize release of information as deemed necessary to treat Participant and to assist with related insurance matters. I authorize all medical providers to bill my insurer directly and Participant will bring an original medical card or a copy of the front and back of the card. Further, I understand that Close Up is not in the business of providing medical care but that Close Up will help Participant get access to quality medical care should Participant require it while on program.

9. FORMS: Participant must bring the following while on a Close Up program: 1) a completed Medical Questionnaire Form, 2) a signed Consent for Treatment Form and 3) health insurance card or a copy of the front and back of card (if Participant has health insurance).

10. MEDICATION: Participant will bring an adequate supply of medication and will self-medicate while on Close Up’s program. I will notify Close Up in advance of all medication that needs to be refrigerated.

11. PROGRAM PRICE: I understand that the program price includes tuition, room and board, in-town transportation, safety and security, activity fees and secondary health insurance. I agree to pay additional charges that might apply for optional items we select such as extra days on program. I understand the program price is subject to change if a deposit is made after the initial deposit deadline.

12. FUEL AND OTHER CHARGES: I understand that Close Up contracts with airlines in advance of the program date in order to ensure that participants can get tickets for the program weeks they select. Should the airlines impose an additional fuel or other charge, I agree to pay that charge as part of the program price. Further, I understand Participant must pay baggage, boarding or other extra airline fees at the airport and directly to the airline.

13. HOTEL CHECK-IN: I understand that Participant must register at the hotel with Close Up staff when Participant arrives on program. Participant may not be able to check into their hotel room until 6:00 pm on arrival day. Close Up will provide a room to store luggage if a sleeping room is not available upon arrival. Close Up is not liable for lost or stolen items from said storage room or for any use of personal property.

14. PAYMENT: I agree to pay Close Up a non-refundable and non-transferable deposit to secure my child’s participation on Close Up. I understand that the first $400.00 of my program payment is non-refundable and non-transferable. Early Bird deposits are also non-refundable and non-transferable. I agree to pay the entire remaining balance no later than 45 calendar days before program start date. For this purpose, I understand that Close Up must actually receive my payment in full by that date. If I or the school chooses to cancel participation on or after the final payment date, no refund will be issued for any payments on account. If I have not made payment in full by 45 calendar days before the program start date, Close Up, at its discretion, may cancel Participant’s enrollment. In the event of a cancellation for nonpayment, Close Up, at its discretion, may allow Participant to re-enroll provided Close Up has available space on its program, provided I make full payment at the time of re-enrollment and provided I pay any and all incremental airline charges that Close Up might incur in booking Participant’s travel to and from your program.

15. LATE ENROLLMENT/ADDITIONAL CHARGES: Close Up welcomes enrollments at any time. However, if a Participant registers for a program within 45 calendar days of its start date, I understand that payment is due in full at the time of registration. Also, since Close Up may be booking my Participant’s travel package so close to the program’s start date, I agree to pay any additional airline charges Close Up might incur, if there are any. Close Up does its best to keep down airfare costs, but air travel is often more expensive when it is not booked far in advance.

16. FINANCIAL AID: I authorize Close Up to withhold any and all awards of financial aid (if any) until I have paid the enrollment fee.

17. DISCLOSURE: I authorize Close Up to share all information on Participant’s application with Close Up employees or their delegates whenever helpful to performing their duties.

18. CREDIT CARD OR BANK ACCOUNT DEBIT CERTIFICATION: By registering Participant for your program, I certify that, if my method of payment is credit card and/or bank account debit, that I have the proper authority to authorize you to charge my credit card or debit my bank’s checking, savings or other account.

19. STUDENT SURVEY: I authorize Participant to be a part of a pre- and post-program evaluation study of civic knowledge. All information collected in connection with this survey is confidential.

20. CERTIFICATION: I certify that all information on this application and any attachment is correct and I agree to advise Close Up in writing of all changes to the information that might occur between now and Participant’s program start date.

VI. TRAVEL INSURANCE

If you are traveling by plane, we recommend that you buy travel insurance. This will protect you against delays, flight cancellations, and other travel-related issues, including illness that prevents you from traveling. You can do so via Travel Guard International, America’s #1 travel insurer. Click here (this will open a new window so you can complete the rest of this form). Please select Close Up Foundation from the list of Tour Operators and select “TOUR/AIR PACKAGE” in the Airline/Charter field. Residents of Washington State must call Travel Guard at 800-826-4919 directly to buy this insurance.

Check the one box that applies:

VII. CLOSE UP MERCHANDISE

Close Up Apparel:

Visit www.closeup.org/purchase/closeupmerchandise to get your official Close Up Washington t-shirts and sweatshirts today! Our high quality merchandise makes the perfect gift and is a great way to remember your once-in-a-lifetime experience.