E4 NYC Application – Jordan Summer 2020 | The American MidEast Leadership Network

About AMLN
E⁴ Programs
Get Involved
Contact Us

About AMLN
E⁴ Programs
Get Involved
Contact Us

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.

First name:

Middle names:

Last name:

Gender: (this is required for organizing accommodations)

Date of Birth:

Home Phone Number:

Mobile Phone Number:

Email:

School Name:

Year/Grade:

Address:

Street number and name:

Municipality:

City:

Country:

Passport Information:

How many passports do you have? 123

Passport 1:

Passport Number:

Passport Expiry Date:

Passport Photocopy:

Do you have a valid US visa on this passport?

US Visa Expiry Date:

Passport 2:

Passport Number:

Passport Expiry Date:

Passport Photocopy:

Do you have a valid US visa on this passport?

US Visa Expiry Date:

Passport 3:

Passport Number:

Passport Expiry Date:

Passport Photocopy:

Do you have a valid US visa on this passport?

US Visa Expiry Date:

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

Full name:

Mobile Number:

Relationship:

Describe relationship:

Emergency Contact #2:

Full name:

Mobile Number:

Relationship:

Describe relationship:

Emergency Contact #3: (Optional)

Full name:

Mobile Number:

Relationship:

Describe relationship:

Allergies & Special Conditions:

Drug Allergies: Do you have any drug allergies? NoYes

Please check all the applicable items and list any others.

AspirinIbuprofenOther

Food Allergies: Do you have any food allergies? NoYes

Please check all the applicable items and list any others.

PeanutsNutsSesameWheat/GlutenShellfishFishDairySoyOther

Other Allergies: Do you have any other allergies? NoYes

Please check all the applicable items and list any others.

DustPollenGrassOther

Do you follow any special diet? NoYes

Do you have any dietary restrictions, other than your allergies? NoYes

Please check all the applicable items and list any others.

PorkDairyOther

Do you have any medical conditions? NoYes

Please check all the applicable items and list any others.

AsthmaDiabetesHigh blood pressureLow blood pressureSinusitusEczemaOther

Do you take any regular medications or require any critical situational medication? NoYes

Please check all the applicable items and list any others.

InsulinAsthma inhalerEpinephrine shots (EpiPen)Other

Do you have any other conditions that could impact your ability to participate in certain activities? NoYes

Please check all the applicable items and list any others.

Motion sicknessFear of heightsOther

CONTACT US

P.O. Box 2156
Long Island City, NY 11102

phone: (347) 924-9674
fax: (917) 591-2177
email: info@amln.org