Office of Student and Program Services

Global Social Change Leadership Institute

July 7-19, 2013

Payments for this program will be accepted by credit card only: VISA, MasterCard, AmericanExpress

Participant Information

All fields marked with are required.

First Name
Middle Initial
Last Name  
Date Of Birth  

Current Mailing Address

Address  
Address 2
City  
State  
Country  
Postal Code
Phone  
Email  
Retype
Email Adress
 

Tuition Payment Information:

Final Tuition Payment
$
 
 
Date:(MM/DD/YYYY)  

Billing Address

First Name
Last Name
Address Line 1
Address Line 2
City
State
Country
Postal Code
 

Cancellation Policy

Cancel on or before June 5, 2013 and receive 50% of their payment, less a $75 processing fee, refunded to their credit card. There will be no reimbursements after June 5, 2013.

I have read this statement and I agree to these terms.