Airport Shuttle Form - Center for Talent Development :: Northwestern ...

AIRPORT TRANSPORTATION FORM
School of Education & Social Policy
SUMMER PROGRAM 2013
617 Dartmouth Place Evanston, IL 60208 847/491-­‐8257
Summer Office: June – August 847/467-­‐2990
Directions: Please fill out all information
O’Hare Airport ARRIVAL Information
Student Name (please print clearly)
CTD Application ID # (in Acceptance letter)
¨AM ¨PM
Arrival Date Arrival Time Airline Flight #
¨ YES ¨ NO
Student’s age at time of flight Unaccompanied Minor* Flight origin (city)
Program: ¨ Solstice ¨ Apogee ¨ Spectrum ¨ Equinox Session: ¨ 1 ¨ 2
*Additional airline fees must be paid to the airline in advance of arrival
O’Hare Airport DEPARTURE Information
Student Name (please print clearly)
CTD Application ID # (in Acceptance letter)
¨AM ¨PM
Departure Date Departure Time Airline Flight #
¨ YES ¨ NO
Student’s age at time of flight Unaccompanied Minor* Flight destination (city)
Program: ¨ Solstice ¨ Apogee ¨ Spectrum ¨ Equinox Session: ¨ 1 ¨ 2
*Additional airline fees must be paid to the airline in advance of departure
Submitting Payment: Airport transportation fee is $40 each way.
If mailing this form to CTD: Attach a check/MO made payable to Center
for Talent Development or provide a credit card number for the total
amount due. Invoicing is not an option for mailed forms.
If e-mailing this form to CTD: complete and check the invoice option in the
Payment Type. DO NOT provide credit card information if e-mailing.
Please supply a name and daytime phone number of a parent or
guardian should there be any questions about flight information.
_____________________________________________________________
Parent Name
_____________________________________________________________
Parent’s Day Phone Number
_____________________________________________________________
Student’s Cell Phone Number
Arrival transportation ($40) $ ____________
Departure transportation ($40)
$ ____________
TOTAL amount enclosed/to charge $ ____________
Payment Type: ¨ Check/money order ¨ Credit Card
¨ Please send me an invoice (e-mail submission only)
Credit Card Information ¨ Visa ¨ MasterCard
Name of Cardholder ____________________________________________
Card Number _________________________________________________
Exp. Date ______________
Cardholder Signature ___________________________________________
For Office Use Only
Date received ___________ Check/CC number ____________ Check/CC amount ____________ Date entered _____________ Entered by _____________