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

HOME ADDRESS                                

PART C -  HEALTH RECORD

PART B - PARENT/GUARDIAN INFORMATION - For students only

ADDRESS

NAME                                                                                                     RELATION                                 

PART D - EMERGENCY CONTACTS (Students list someone other than your parents)

HOME PHONE

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                                                         

ST

CITY

ST

CELL

NAME OF TOUR LEADER

NAME OF SCHOOL

E-MAIL - REQUIRED (Parents, Adults, Teacher/Chaperone)

HOME PHONE - REQUIRED

CELL - REQURED

ST

ZIP CODE

CITY

If NO, what is your citizenship? __________     

 

Are you a US citizen? YES (   )  NO (   )

PASSPORT #

Student or Adult check here (  )  Teacher/Chaperone check here(  )           Male (  ) Female (  )

DATE OF BIRTH - MM/DD/YYYY

CITY

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.

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