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All Access Medical Internship Enrollment Form Hue, Vietnam | July 19-August 4, 2018 Tuition for FutureDocs Abroad 2018 Vietnam is $6,250.00. All elements included in Tuition and not included in Tuition are fully enumerated in Section III of the FutureDocs Abroad Terms and Conditions. Spaces are filled strictly on a first-come-first-served basis. If spaces are no longer available, payments will not be processed and will be returned. Spaces are secured through the Student’s full payment or $1,000.00 deposit. FutureDocs Abroad will confirm enrollment, in accordance with Section II of the FutureDocs Abroad Terms and Conditions, when the Student pays the full and correct tuition. No refunds will be honored. We recommend enrolled students purchase trip cancellation insurance to cover any cancellation due to emergencies and sickness. Please complete all the information below Step 1: Complete Student Information Section Student Name: ________________________________________________________________________ D.O.B.: _______________________ Gender: M F First Last Address: ______________________________________________________________________________________________________________________________ City: ___________________________________________________________________ State: __________________________ ZIP: _________________________ Student Email: _________________________________________________________ Student Phone: ________________________________________________ Emergency Contact: ___________________________________________________________________ First Last Phone Number: _________________________________________________________ Relation: ________________________ Step 2: Select Your Preferred Payment Option Check or Money Order made payable to “The National Leadership Academies” Option 1: Full payment: $6,250.00 Option 2: Payment Plan: First payment of $1,000.00 due today, and $5,250.00 due in 60 days. Please enclose both checks or money orders (first dated today and second dated 60 days from today). Credit Card: Please select your preferred payment option and enter your credit card information below: Option 1: Full Payment*: Please charge the credit card below $6,250.00 Option 2: Payment Plan: Please charge the credit card below $1,000.00 today, then five payments of $1,050.00 to be automatically charged every 30 days until paid. * PayPal Credit is also offered as a payment option. Please call our Admissions Office at (888) 986-6563 if this is your choice payment option. Visa/MC/Amex/Discover Number: _____________________________________________________________________________________________________ Card Expiration Date: __________________________ Card Security Code (CVV): _______________ Cardholder’s Name (As it appears on card): _______________________________________________________________________________________________ Billing Address: ________________________________________________________________________________________________________________________ City: ___________________________________________________________________ State: __________________________ ZIP: _________________________ Signature of Cardholder: _________________________________________________ Date: _______________ Step 3: Send the Completed and Signed Forms You must send the completed Enrollment Form and signed Terms and Conditions and Code of Conduct to the National Leadership Academies (the “Documents”). You may: 1. Email the documents to [email protected]; 2. Fax the documents to (888) 316-2298; or 3. Mail the documents to: The National Leadership Academies, 1701 Pennsylvania Ave NW Suite 300, Washington, DC 20006*. *Note: If payment is made by check or money order, the Documents, along with check/s or money order/s, should be sent by Mail only. I have carefully read, agree to, and will abide by, the FutureDocs Abroad Code of Conduct and Terms and Conditions. These three documents (Enrollment Form, Terms and Conditions, and Code of Conduct) constitute the entire understanding between the parties with respect to its subject matter, superseding and replacing any and all prior agreements, communications, and understandings, both written and oral. ________________________________________________________________________ Student Signature Date
