Student Application for China Trip

All required fields are listed in "Bold"
Name
Primary Address:
Secondary address:
Email address:
Phone number:
Mobile phone number:
Emergency contact info:
Birth date (mm/dd/yyyy):
Age:
Gender:	Male Female
Instrument:
Orchestra:	BYS LYSO CYSO Other
Parents’ names:
Parents address if different from yours:
Parent’s phone numbers:
Parent's E-mail addresses:
Indicate if one or both of your parents are applying to go on the trip, and if so which one(s):	Mother Father Both
What medication do you take regularly (if none, then enter "none")?
What medication will you be bringing with you on the trip (if none, then enter "none")?
Give details of any allergies (if none, then enter "none"):
Please specify any dietary restrictions or preferences you have (if none, then enter "none"):
Describe any physical or emotional conditions you have that may require special treatment or attention at any time during the trip (if none, then enter "none"):
Do you need financial aid? If so, how much do you think you will need?
Do you intend to engage individually in fund raising activities?	Yes No
Would you participate in group fund raising activities organized by BYS?	Yes No
List name and contact information for any medical insurance you may have that would provide coverage while you are outside the U.S. (if none, then enter "none")	;
Would you like to obtain trip cancellation or trip interruption insurance, depending on cost? If so, which?	Trip Cancellation Trip Interruption Insurance
Do you have a passport?	Yes No
Passport expiration date (mm/dd/yyyy):
I would like to bring with me:	Laptop Mobile phone Camera
I have the following vaccinations that are valid for a period that expires after June 17, 2010:
Please click the "Submit Application" button only once, unless you need to correct an omission, in which case you will need to use your browser's "Back" button and re-submit.