Clifford M. Lewis, S.J. Appalachian Institute

Clifford M. Lewis, S.J. Appalachian Institute

2011-2012 Service/Immersion

Trip Registration Form

Institution:
Trip Coordinator:
Name:
Phone:
Email:
Trip Dates:
*All trips will begin on Sunday afternoon/evening and end Friday afternoon. To determine the best travel arrangements for your group please discuss your options with the staff at the Appalachian Institute.
Travel Information (Time and Location):
Arrival:
Departure:
Number of vehicles:
Number of Students Attending: Number of Staff Attending:
Number of Male Students: Number of Female Students:
*This number determines the cost of the trip, and can impact lodging/ service opportunities. If you do not know the exact number at this time please give your best estimate, and contact us with an exact number as soon as possible. There is a minimum of ten. Groups with less than ten people will be charged for ten.
Name(s) of Group Leaders: Please Indicate if Leaders are Students or Staff Members
Name:
Phone:
Name
Phone:
Service/Educational Site Preferences
ie: what kind of specific information (for Energy/Public Health) or what type of service is your group most interested in?
Your School / Organization Facebook page:
Additional Questions or Comments:

Please fill out completely and return to the Appalachian Institute with your non-refundable deposit of $300.

If you have any questions please email or call(412)418-6299 or (304) 243-6241

Please Make Checks Payable to: The Clifford M. Lewis, S.J. Appalachian Institute

Wheeling Jesuit University

316 Washington Avenue

Wheeling, WV 26003