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

OFFICIAL INTERNATIONAL CLASSROOM APPLICATION - 2012 TOURS

STUDENTS,TRAVELING ADULTS AND TEACHER/CHAPERONES 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

CITY

CELL

NAME OF TOUR LEADER

NAME OF SCHOOL

PARENTS E-MAIL REQUIRED (not students) Print clearly, case-sensitive or type it out & attach

HOME PHONE - REQUIRED

PARENT CELL - REQURED

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.

We communicate by email & it must be legible.