Application: Tayra Educational Expeditions programs 2023
What program are you enrolling to: 
Passport Information 
Name:
 *
Nationality: *
Passport expiration date:
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YYYY
 Birth date:
MM
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DD
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YYYY
Mobile Number:
Address Street:
City and Country:
Postal Zip Code 
Student e-mail address
University Or School You Are Currently Attending:
Status (Freshman, Sophomore, Junior, Senior): 
Major And Minor
Overall GPA And GPA Of Your Last Completed Semester:
Why do you want to take this course?
What do you hope to gain by taking this course?
What courses have you taken which may have prepared you for this course?
Will you be taking this course for credit? If so, do you need assistance in arranging it? If so, please provide us with a relevant contact.
What special skills do you have which may have prepared you for this course?
Emergency Contacts and Insurance. 
Emergency Contact #1
Emergency Contact #2
Primary Health Insurance Company Name, Address And Phone Number:
Primary Health Insurance Company Group And Member Number:
 Travel Insurance Company Group And Member Number:
Physician Name
Physicians Office Number 
Physicians After Hours Number and Email
 Street 
City

Liability Release And Indemnification For Tayra Educational Expeditions.

The above named student, am eighteen years of age or older. I have voluntarily applied to participate in the Tayra Educational Expeditions course.  

I acknowledge that the nature of this field course may expose me to hazards or risk that may result in my illness; personal injury or death and I understand and appreciate the nature of such hazards and risks. In consideration of my participation in these Tayra Educational Expeditions course I hereby release Tayra Educational Expeditions, its governing board, officers, employees and representatives from any and all liability to me, my personal representatives, estate, heirs, next of kin, and assigns for any and all claims and causes of action for loss of or damage to my property and for any and all illness or injury to my person, including my death, that may result from or occur during my participation in the Tayra Educational Expeditions course, whether caused by negligence of Tayra Educational Expeditions, its governing board, officers, employees, or representatives, or otherwise. I further agree to indemnify and hold harmless Tayra Educational Expeditions and its governing board, officers, employees, and representatives from liability for the injury or death of any person(s) and damage to property that may result from my negligence or intentional act or omission while participating in the described course.

I have carefully read this agreement and understand it to be a release of all claims and causes of action for my injury or death or damage to my property that occurs while participating in the described activities or trips and it obligates me to indemnify the parties named for any liability for injury or death of any person and damage to property caused by my negligence or intentional act or omission.

I accept the terms of this agreement. 

I certify that the information on this application and its supporting documents is accurate and complete. I understand and agree that failure to fully complete the form, or misrepresentation or omission of facts, represents grounds for elimination from consideration for selection to this course if discovered later. 

I authorize Tayra Educational Expeditions to investigate, without liability, all statements contained in this application and supporting materials.

I authorize references, to make full responses to any inquiries in connection with this application for acceptance. 

I also certify that full payment will occur by the correct due dates stipulated on the Tayra Educational Expeditions website, or that I will have made payment by installments with prior approval of Tayra Educational Expeditions faculty.

I do certify that I have completed this application to the best of my knowledge and that all information is accurate. 


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