Blue Ridge Community College
Program Name: ______________________________________________________
Personal Information
_______________________________________________________________________
Last Name First Middle
________________________________________________________________________
Street City State Zip Phone
Email Address: ________________________ Date of Birth: _______________________
Female Male
Citizenship Status
U.S. Citizen yes no
Legal Permanent Resident: Alien Number: _______________________
Non-Immigrant Student: Status: _______________
You must travel with a valid passport? Please provide this information
Issuing Country ____________________________________________
Passport Number ___________________________________________
Are you a currently enrolled as a BRCC Student? Yes No
Other Information
On some trips, Blue Ridge Community College has the policy "You go with the instructor(s) and you return with the instructors" Blue Ridge Community college reserves the right to alter this policy and the itinerary of the program at any time in response to conditions that the trip leaders believe will affect the operation of the program and/or the health and safety of the participants.
Agreement:
I affirm that the information given in this application is true to the best of my knowledge.
________________________________________________________________________
Signature Date