college tour 2013
TRANSCRIPT
Epic Empowerment’s AnnualSpring Break College Tour April 10 - 12 2013
Georgia Southern & Valdosta StateFAMU & Florida State University*
The Epic Empowerment College Readiness Tour is an opportunity for 8th-12th grade students to gain first hand exposure to various aspects of college life. Students will visit
some of our nation’s HBCU’s and other top national universities. This tour provides students with information regarding school selection, cost, admission requirements, the application process, financial aid, and elements of campus life. Allow your future scholar to join us for this educational and culturally enriching journey during Spring Break 2013!
April 10 - April 11 Tour Schools April 12th Tour Fun Day at Universal Studios
Cost $390.00 Per StudentSee attachments for more information
*Tentative School Schedule Based on Availability. Subject to Change*
Epic Empowerment College Tour 2013
Price Includes:Luxury Coach Bus Transportation
(2) Night Hotel Stay(3) Breakfast Meals
(3) Lunch Meals (2) Regular Dinner Meals and
(1) Mature/Formal Dining ExperienceFun Day - Universal Studios
Cultural ActivityEpic Empowerment T-Shirt & Pennant
Payments: $65.00 (Reserves Seat)
Monthly Payment Plan Option! (See Page 7)Balance must be paid in full by
March 15th, 2013
Limited Seats Available Reserve Today!www.epicempowerment.com or 678-592-5036
Make Checks or Money Orders Payable to: Epic Empowerment Enterprises
All payments are Non-Refundable unless trip is cancelled, however 15% of amount paid will be withheld to cover expenses paid to transportation, hotel provider and other vendors or suppliers.
Epic Empowerment College Tour 2013
Parent Permission Form
I would like my student, ______________________________, to participate in Epic Empowerment College Readiness Tour 2013 from April 10 - 12, 2013.
I give permission for Epic Empowerment Enterprises to provide transportation for my child, (listed above), during the College Tour 2013. Parent/Guardian Name _________________________________________________________
Contact Phone Number __________________________________________________________
______ I acknowledge that all payments are Non-Refundable unless trip is cancelled,
however 15% of amount paid will be withheld to cover expenses paid to transportation and
hotel provider.
Parent/Guardian Signature _____________________________________________________
Student Information: Print Clearly
Student Name: _________________________________________________________________
Age:________Date of Birth:_____________________ T-Shirt Size_______________________
School: _____________________________ Grade Level: ______________________________
Allergies/Medical Issues: ________________________________________________________
Medications: __________________________________________________________________
Epic Empowerment College Tour 2013
Parent/Guardian Information
Parent/Guardian Name: __________________________________________________________
Parent/Guardian Name: __________________________________________________________
Mailing Address: _______________________________________________________________
City: ____________________________ State: ________ Zip: ___________________________
Email Address:_________________________________________________________________
Home Phone: __________________________ Cell Phone: _____________________________
May we send you trip updates via text: Yes ____________ No ___________________________
Emergency Contact Person: ______________________________________________________
Emergency Contact Number: _____________________________________________________
Relationship to Student: _________________________________________________________
Please complete and return these forms along with a copy of your student’s Insurance card. The initial deposit is due
immediately in order to secure your student’s space! Remember spaces are limited and they will fill up quickly.
Epic Empowerment College Tour 2013
Medical Release
In the event that my child should get hurt or become ill during this trip, the following signature will release Epic Empowerment Enterprises, LLC, and it’s chaperones from any liability. Trip organizers have my permission to seek medical attention and to act with his/her best judgment should any medical situation arise. Please provide a copy of his/her medical insurance card in the event that we need to take him/her to the hospital.
_______No, my child has no known health impairment(s) or allergies.
_______Yes, my child has the following health impairment(s) or allergies:
______________________________________________________________________________
______________________________________________________________________________
Student name __________________________________________________________________
Parent signature ________________________________________________________________
Telephone #_________________________Emergency phone ___________________________________
Epic Empowerment College Tour 2013
Photo Release Form
I certify that I am the parent or legal guardian of ________________. I give permission for my child to be filmed, and photographed during the events and programs through the Epic Empowerment College Tour, for the purposes of developing promotional materials for the program. I understand that neither my child nor I will receive compensation for the use of photos, videos or any other marketing material.
I herby grant full permission to Epic Empowerment Enterprises, LLC, to use, reproduce, publish, distribute, and exhibit my child’s name, likeness, and voice in connection with these materials.
I herby release and forever discharge Epic Empowerment Enterprises, LLC, their members individually, and their officers, agents and employees, from any and all claims, demands, rights, in my capacity as legal representative of my child, caused by or arising from the production or use of these materials.
I understand that the acceptance of this consent and release and forever discharge Epic Empowerment Enterprises, LLC from all claims, demands, and causes of action which, I, My heirs, representatives, executors, administrators, or any other persons acting on my behalf or on behalf of my estate have or may have reason of this authorization.
______________________________________________________________________________
STUDENT NAME
______________________________________________________________________________
SIGNATURE (PARENT/GUARDIAN)
______________________________________________________________________________
PRINTED NAME (PARENT/GUARDIAN) DATE
Epic Empowerment College Tour 2013
Payment Plan
If you wish to utilize our monthly payment plan, please indicate that on this page. You may make payments based on this schedule; however, at
anytime you can opt to pay the balance in full.
Payment Due Dates: Payment AmountsFriday, September 28, 2012 (Deposit) $65.00
Wednesday, October 31, 2012 $65.00
Friday, November 30, 2012 $65.00
Tuesday, January 31, 2012 $65.00
Thursday, February 28, 2013 $65.00
Friday, March 15, 2013 (Final Payment) $65.00
____ Yes, I would like to utilize the payment plan.
Signature_________________________________________________
Email_____________________________________________________
Make Checks and or Money Orders Payable to Epic Empowerment College Tours.
Epic Empowerment College Tour 2013
For further information please contact the individuals listed below:
Mr. Kevin Mason, M.Ed, CAMS Mr. Anthony Outler, MS.Ed, CAMSCo Organizer Co OrganizerP.O. Box 54641 P.O. Box 54641
Atlanta, GA 30308 Atlanta, GA 30308
678-595-3107 678-592-5524 [email protected] [email protected]
Visit us on FACEBOOK: Epic Empowerment College Readiness Tours
Please complete and return these forms along with a copy of your student’s Insurance card. The initial deposit is due
immediately in order to secure your student’s place!
www.epicempowerment.comP.O.Box 54641
Atlanta, GA 30308678-595-3107 & 678-592-5524