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Name and Address of Registrant(s) (only one form is needed for couples) Name(s):________________________________________________________________ Address:________________________________________________________________ Telephone: Home (____)___________________Cell(____)_______________________ E-Mail:_________________________________________________________________ Emergency Contact Name: _________________________________ Relationship: __________________________Telephone Number (____)_____________ Address:________________________________________________________________ ROOMING PREFERENCES ____We want a double room occupancy. ____I want a single room where available. A single occupancy supplement will be assessed. ____I want to share a room. If a roommate is unavailable, a single occupancy supplement will be assessed. ____I smoke ____I do not smoke HEALTH Do you have any disability or illness that might restrict your full involvement in any aspect of the tour or about which we should be aware for your safety (e.g. walking difficulties, diabetes, angina etc.)? ______NO ______YES (please provide full details on a separate sheet) If you have other Special requirements (e.g. dietary restrictions), please advise us and we will do our best to accommodate you:_______________________________ I/We declare that I/We have read and understand the Terms and Conditions Signed:_______________________________ Date:___________________________ Signed:_______________________________ Date:___________________________ Enclosed is: $300 deposit (per person): ________ Payment in full: __________ |