Global Academics

Registration Form

If you have not registered, and wish to travel with Global Academics in the future, please complete the registration below.

Choose Username *

Your email address *

Choose a password *

Type password again *

Address *

Address 2

City *

State *

Zip *

Primary Phone *

Cell Phone *

Are you an educator/teacher? * yes no

If you answered yes, where do you teach/work? School:

If you are not a teacher, what is your profession?

Are you a college/university student? * yes no

If you answered yes, where do you attend?

If not are you willing to enroll as one for this trip? yes no

Are you a U.S. Citizen? * yes no

If No, what is your country of citizenship?

Do you have a current U.S. or other passport? (valid passport required to travel outside the U.S.) yes no

If you answer yes, be sure to fill out the next 3 questions

U.S. Passport or other country?

Passport Number

What is your passport expiration date? (mm/dd/yyyy)

I, (state your name) *

Agree to:

Secure a valid passport and ensure that it does not expire 6 months before of after your dates of travel.
Complete all paperwork required
Pay the full amount due by the deadlines of the payment plan
Sign all waivers

Understand that:

I will receive updates and critical info by email
$500 non-refundable deposit that counts towards the total due

Signature (type your full name IN CAPS to signify your agreement) *

Today's Date *

You may also, print this form and mail it along with your deposit. Make your money orders/checks payable to Global Academics and mail all documents to:

Global Academics
Attn: Dr. Siri Brown
4100 Redwood Rd #376
Oakland, CA 94619

Contact: Dr. Siri Brown,
Professor of African American Studies
510.649.5664
www.global-academics.org

PLEASE ADD [email protected] TO YOUR ADDRESS BOOK, AND CHECK YOUR SPAM FOLDER FOR YOUR REGISTRATION CONFIRMATION LINK.

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test, _{500 san pablo avenue, albany, ca}