PLEASE PRINT LEGIBLY IN INK - NO MARKERS OR PENCILS PLEASE
NAME - (EXACTELY as it is or will be on your passport))
FIRST MIDDLE LAST
PART A - PARTICIPANT INFORMATION
PLEASE MAKE A COPY OF THE APPLICATION FOR YOUR RECORDS
INTERNATIONAL CLASSROOM APPLICATION - 2011
TEACHER / CHAPERONES, TRAVELING ADULTS AND STUDENTS MUST COMPLETE ALL SECTIONS AND SIGN BELOW
International Classroom Inc. operates in association with Bravo Tours of Warwick New York
( ) Yes, I have applied for trip insurance ( ) No thank you
Parents signatures are required for participants under 21
ADDRESS: IF DIFFERENT FROM ABOVE
NAME OF PARENTS/GUARDIANS
PART B - PARENT/GUARDIAN INFORMATION - For students only
PART D - EMERGENCY CONTACTS (Students list someone other than your parents)
Participants Signature________________________________________________ ____Date____________
Father/Legal Guardian Signature_________________________________________ __Date_____________
( ) I have enclosed my deposit.
Have you ever suffered a medical disorder requiring psychiatric treatment? Yes ( ) No ( )
If yes, please describe______________________________________________________
Is your general health good? Yes ( ) No ( ) List any special medical care _________________________________
I / WE HAVE DOWNLOADED, READ AND AGREE WITH THE CONDITIONS SET FORTH IN THE TWO FORMS ENTITLED:
TERMS AND CONDITIONS - AGREEMENT AND RELEASE
E-MAIL - REQUIRED (Parents, Adults, Teacher/Chaperone)
If NO, what is your citizenship? __________
Are you a US citizen? YES ( ) NO ( )
Student or Adult check here ( ) Teacher/Chaperone check here( ) Male ( ) Female ( )
DATE OF BIRTH - MM/DD/YYYY
PART E - AGREEMENT AND RELEASE
Mother/Legal Guardian Signature_____________________________________Date____________
NOTE: Your reservation will not be made without a completed and signed application along with the deposit.