Roanoke College Business Office

Summer 2024 – Individual Registration

Housing Blocks

Dates 5/13/2024 – 6/9/2024 Price $975.00 Spaces Remaining 25

Dates 6/10/2024 – 7/7/2024 Price $975.00 Spaces Remaining 22

Dates 7/8/2024 – 8/9/2024 Price $975.00 Spaces Remaining 26

Payment is only due for the first registered housing block at the time of registration. All subsequent housing block registrations will be invoiced later.

Personal Information

First Name

Middle Name

Last Name

Affiliated Institution College/University primarily attended

Phone Number

Email Address

Date of Birth

Gender

Male Female Beyond the Binary

Permanent Address

Country

Street Address

City

State

Postal Code

Emergency Contacts

Contact #1

Full Name

Relation to Intern

Daytime Phone Number

Cell Phone Number

Contact #2

Full Name

Relation to Intern

Daytime Phone Number

Cell Phone Number

Internship Information

Company Name

Internship Supervisor

Supervisor Contact Phone Number

Supervisor Contact Email Address

Permission to Treat

By accepting this agreement, I give permission for

Roanoke College employees to administer first-aid to me in the event that I am unconscious or otherwise unable to give consent;
medical personnel to treat me in the event that I am unconscious or otherwise unable to give consent.