History 276 This Land is Your Land

Page 1

Personal Information

First Name:

Last Name:

Phone:

Email:

Mailing Address

Address:

City:

State:

Home Address

Address:

City:

State:

Health Insurance

PLEASE NOTE: You must show proof of Health Insurance during your stay on Nantucket

Name of Health Insurance Company:

Policy Number:

Page 2

Emergency Contact

First Name:

Last Name:

Relationship:

Phone:

Email:

Page 3

Academic History

Name of Institution Presently Attending:

Matriculated:

YesNo

Major:

Minor(s):

Cumulative GPA on 4.0 Scale:

Page 4

Program Preference

Please indicate your housing preference.
Note the program costs of each below:
With housing: $ (includes housing, fees and tuition*)
Without housing: $ (includes fees and tuition* only not housing)

The course fee does not cover meals, or transportation to and from Nantucket Island.

Please indicate which course you are applying to and your housing preference.

History 276 with housingHistory 276 without housing

Gender:

FemaleMaleNon-binaryPrefer not to say

Page 5

Application Certification

TRAVEL ARRANGEMENTS

Program participants are responsible for making their own travel arrangements to and from Nantucket Island. Information on ferries will be provided.

TERMS AND CONDITIONS

Dates:

The course starts on Tuesday May 30th.

Fees

*Please note: the fee does not cover meals, books, insurance, or travel to and from Nantucket Island. Bunkhouse housing provides two bathrooms and two bedrooms of bunkbeds, shared full kitchen, dining room, and conference/lounge space.

Program fees BIOL 344

With housing: $ TBA (includes housing, fees and tuition for 4 credits, it includes the BIOL 345 Fee of $900.00)
Without housing: $ TBA (includes fees and tuition for lecture and lab for 4 credits only, does not include housing, it includes the BIOL 345 Fee of $ TBA)

THE APPLICATION DEADLINE IS May 1st, 2024.

The total program fee* covers classroom instruction and housing on Nantucket. It does not cover meals, or transportation to and from Nantucket Island.

The University of Massachusetts Boston cannot assume responsibility for any sickness or accident incurred by the student during his or her stay on Nantucket Island, nor does the University provide any casualty or health insurance. Participants are required to provide proof of health insurance coverage before registering for the program.

I UNDERSTAND THAT PARTICIPATION IN THIS PROGRAM IS GOVERNED BY THE ABOVE TERMS AND CONDITIONS TO WHICH I CONSENT TO BE BOUND.
I understand that the course starts on Tuesday May 28th.
In place of your signature, please type your full legal name

If applicant is under 18, please type the parent of guardian's full legal name in place of signature

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