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