NORTHERN VIRGINIA COMMUNITY COLLEGE
DIVISION OF HUMANITIES AND SOCIAL SCIENCES
ALEXANDRIA CAMPUS
3001
North Beauregard Street
Alexandria, Virginia 22311
Study Trip to
Snow Shoe, West. Virginia
October 2-3, 2004\
Name (Last) _________________________(First
&
Middle_______
(Please print)
Social Security Number: __________ NVCC
Student _____Yes _______No
Member
of the Alexandria Campus history Association ______Yes ______No
Street Address: ______________________________________________________________
City: ________________________
State: ________ Zip Code: ___________
Telephone: _________________ (Home) _____________________ (Work)
Are you under doctor's care? ( ) Yes ( ) No
Are you on medication?
( ) Yes
( ) No
If you answered yes to
either of the above questions, please specify on the back of this sheet.
************************************************************************************************************
Please indicate whom we should contact in case of an emergency:
Name:
______________________________________________________________________
(Last)
(First)
Street Address: ______________________________________________________________
City: _______________ State: _____________ Zip Code: _______________
Telephone: __________________ (Home) ____________________ (Work)
Cost to Students:
$195.00
(Covers Bus
Transportation,
overnight at Inn at Snowshoe, and two-hour train ride on Cass Railway.
A single room will cost an additional $45.00.
It is required that sign a Waiver of
Responsible before leaving the NVCC campus.
If
you do not have a NVCC Parking Pass, the charge for parking on campus is
$2.00 per day.
Your parking pass will be given to you on the morning of departure. The
bus departs from the Alexandria Campus at 7:30 a.m.
_______________________________________________Room-mate
Amount Enclosed____________________ (Make check payable to Travel
Seminars)
Mail your application and payment to the following address:
Dr. Jean H. Braden
Northern Virginia Community College
Alexandria Campus
Humanities and Social Sciences Division
3001 North Beauregard Street
Alexandria, Virginia 22311