A Day in the Life of Speech-Language Pathologists & Audiologists

Augustana Speech & Language Summer Experience

PLEASE COMPLETE ALL OF THE INFORMATION REQUESTED BELOW

STUDENT INFORMATION

First name *

Preferred Name/Nickname

Last Name *

Student Email Address *

Parent or Legal Guardian Email Address *

Birthdate *

Mailing Address *

Country

Street

City

Region

Postal Code

Student Cell Phone

Parent/guardian cell phone

Parent/guardian email

Emergency Contact First Name, Last Name, Relationship

Emergency Contact Cell Phone

T-Shirt Size

High School *

Year of High School Graduation

Special Accommodations/Needs

In order for Augustana College to make this a great experience for you, please inform us of any special accommodations you may need for meals or in the classroom.

CANCELLATION POLICY:

Courses not meeting minimum enrollment may be canceled and a refund will be issued.
Once a course capacity has been met, students can choose to be placed on a wait list and will be notified should an opening become available.
Students who sign up for a course and cancel their registration before June 1 will be entitled to a full refund.
Registrations canceled after June 1 will not be refunded

CANCELLATION POLICY:

Courses not meeting minimum enrollment may be canceled and a refund will be issued.
Once a course capacity has been met, students can choose to be placed on a wait list and will be notified should an opening become available.
Students who sign up for a course and cancel their registration before June 1 will be entitled to a full refund.
Registrations canceled after June 1 will not be refunded

I have read and understand the cancellation policy above

I understand that photos or videos may be taken during my visit. I give permission for Augustana College to use my image for promotional purposes.

Yes

No

I will submit the program fee of $120 within 7 days. Instructions will follow with more detailed payment information.

I plan to mail a check to Augustana College

I plan to call with credit/debit card information

Thank you for participating!