2006 Summer Medical Institute Commitment Form

 

Name:___________________________

E-mail Address: __________________________________

Phone Number: _______________________________

Health Insurance Provider: ______________________________

 

I, _______________________, understand that by signing this commitment form, I am reserving a place for myself on the SMI 2006 Romania trip. I understand the following rules and regulations and agree to all terms below:

  • All paperwork is due no later than March 1, 2006, If I do not have an application in, I understand I do not have a reservation for SMI 2006.
  • The breakdown of when money has to be in is as follows:
  • Total of $500 by March 15th
  • Total of $1000 by April 17th
    •  
  • Total amount of trip (~$1900)  by May 5th

    • - I am responsible for the full cost of the trip (airfare, ground costs, etc.). If my fund raising support doesn’t fully pay for the trip, I understand that I am responsible for the remainder.

    - I understand that the full amount of the trip must be paid by May 5th, 2006 or I will not have a plane ticket purchased for me for SMI 2006 resulting, in not going on the trip, with no refund of the support raised.

    - If I cancel my reservation at any time, no money will be refunded.

     

  • I understand that the full amount of the trip must be paid by May 5th, 2006.

    •  

    ________________________________________________

    SIGNATURE DATE