E4 – NYC : Application
Jordan Summer 2020

Dates: July 1st , 2020 – July 14th , 2020
Price: $5,000

For more information, please contact Dr. Omar Tayeh:
Mobile: +(962) 79 577 6330
Email: otayeh@yahoo.com


    Student Information:

    Please enter your full name, as it appears on your passport.

    Address:

    Passport Information:

    123

    Passport 1:

    Passport 2:

    Passport 3:

    Emergency Contacts:

    Please provide at least two emergency contacts. All emergency contacts must be adults (above the age of 21). One of them must be your guardian.

    Emergency Contact #1: Primary Guardian

    Emergency Contact #2:

    Emergency Contact #3: (Optional)

    Allergies & Special Conditions:
    NoYes

    Please check all the applicable items and list any others.

    AspirinIbuprofenOther
    NoYes

    Please check all the applicable items and list any others.

    PeanutsNutsSesameWheat/GlutenShellfishFishDairySoyOther
    NoYes

    Please check all the applicable items and list any others.

    DustPollenGrassOther
    NoYes

    NoYes

    Please check all the applicable items and list any others.

    PorkDairyOther
    NoYes

    Please check all the applicable items and list any others.

    AsthmaDiabetesHigh blood pressureLow blood pressureSinusitusEczemaOther
    NoYes

    Please check all the applicable items and list any others.

    InsulinAsthma inhalerEpinephrine shots (EpiPen)Other
    NoYes

    Please check all the applicable items and list any others.

    Motion sicknessFear of heightsOther