Havana Field Course

Name (as it appears on your passport)(Required)

First Middle Last

Email(Required)

Registration(Required)

Confirmation Deposit (all students) $200.00

PAYMENT 2 (Non-GINS students): Remaining Balance $2369.00

PAYMENT 2 (GINS students): Remaining Balance $2769.00

Date of birth(Required)

Carleton ID number(Required)

Year of study(Required)

Passport number(Required)

Passport country of issue(Required)

Passport expiry date(Required)

Emergency contact 1

Emergency Contact 1: name(Required)

First Last

Emergency contact 1: Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Emergency contact 1: Email(Required)

Emergency contact 1: Phone number(Required)

Emergency contact 1: Relationship(Required)

Emergency contact 2

Emergency contact 2: Name(Required)

First Last

Emergency contact 2: Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Emergency contact 2: Email(Required)

Emergency contact 2: Phone number(Required)

Emergency contact 2: Relationship(Required)

Copy of photo page of passport

Drop files here or

Accepted file types: jpg, pdf, png, Max. file size: 15 MB.

Allowed file types: jpg, pdf, png Maximum image size: 15 MB

Additional comments (optional)

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