Student Profile - Wichita State University

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					             Spring 2012 Berlin MGMT 885 Student Profile
1.    Name (as it appears on your passport) _________________________________________________

      Birthdate and Country of Birth _____________________________________________

      Passport Country and Number ________________________________________________________

      Email _________________________________________________

      Wichita Address ______________________________________________________________________

      Student Cell Phone and if you have one, home phone number including area codes


2.    Would you be willing to share a hotel room (2 beds) in Berlin with another Barton School MGMT 885
      student? If so, please list the name of the person would like to room with. Please note: A single room
      will cost significantly more than a double room.

          _______ Yes, I would be willing to share a room. I would be willing to room with the
          following student(s) __________________________________________

          _______ No, I wish to have a room by myself. (Will mean a higher hotel charge.)

3. Please list any WSU student(s) that you would like to have as a teammate for the Berlin/Barton
   School MGMT 885 project. Please note that not all requests for teammates will be granted.


4. Please indicate if you have any food allergy or other food-related issue that requires a special diet.
   (We will use this info to order special food during the flights and during any events.)
       ________ Yes. Please describe _________________________________

          ________ No

5. Emergency Wichita Contact While in Berlin

     Name ___________________________________________________

     Telephone Number __________________________________________

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I (name) ________________________________ agree to participate in the Spring 2012 MGMT 885
Berlin Experience MGMT 885 trip scheduled for January 6-14, 2012. I understand that only after I
submit this form that my enrollment eligibility will be secured. I understand that I will be responsible
for any costs associated with the cancellation of my enrollment in this program after travel
reservations have been made.

Signature _______________________________________________

Please complete this form, sign it, and send/fax/bring/email to the Barton School Dean’s Office (see below for
address) no later than September 2, 2011.

                                          Barton School Dean’s Office

                                             Attn: Dorothy Harpool

                                                100 Clinton Hall

                                            Wichita State University

                                            Wichita, KS 67260-0048


                                                 Fax: 978-3845

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