Tour name by school or group associated with: |
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Travel destination: |
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Dates of planned travel: |
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Name of teacher/group leader associated with the tour: |
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First name of tour participant including middle initial (Passport Name): |
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Last name of tour participant (Passport Name): |
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Date of Birth: |
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Gender: |
male
female
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Traveler’s e-mail address: |
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Are you a US Citizen? |
yes
no
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Mailing address:
(Please include Street, City and Zip Code) |
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Home telephone: |
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Traveler’s Cell phone number: |
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Name and contact information for parent/guardian: |
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Emergency Contact Info: |
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Health Card Information including name of health insurance, group and/or policy number, doctor name and contact number, allergies to drugs or food, medications being used, and special health concerns or instructions for group leaders: |
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Full names, contact numbers and length of time they have known the traveler of at least 3 different people not related to traveler for personal references and required recommendations: |
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Signature: |
Date: |
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