Personal Information

Enrollment form

A valid enrollment package should include: the completed Enrollment Form and $300 Enrollment Fee.

* Indicates required field

Name *

First

Last

Place of Birth *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Email *

Passport/Visa Information

* Please provide the following if available

Passport Number *

Experation Date *

Visa Number *

Experation Date *

Emergency Contact Information

Father's/Guardian's Name *

Mother's/Guardian's Name *

Father's Address *

Mother's Address *

Father's Address *

Line 1

Line 2

City

State

Zip Code

Country

Father's Phone Number *

Father's Email *

Mother's Address *

Line 1

Line 2

City

State

Zip Code

Country

Mother's Phone Number *

Mother's Email *

Name ( in full) of Emergency Contact Person ( if different from above ) *

Relationship of Emergency Contact Participant *

Emergency Contact Address *

Emergency Home Phone *

Emergency Office Phone *

Emergency Contact Email *

Additional Information *

Health/Accident Insurance Card

* If you have please scan a photocopy of your insurance card ( front and back) and send to [email protected]

Submit

To signify your intention to attend, please submit the Enrollment Form along with a
non-refundable deposit* of $300

Other forms of payment:
1) Venmo

Username: Brendan-Warford

*Note: This advance fee is credited toward the total cost of “DESIGN H(ij)ACK”. If decided to pull out before coming to china this fee will not be deductible. The final payment of $2,200 (if not adding hotel package) or $2,750 (if adding housing package) must be paid by June 5th.

***Once Enrollment form has been submitted with fee, we will forward you the welcome package, as begin to prepare you for Beijing.

Enrollment form

Enrollment form

ADDRESS:

CONTACT: